The Journal of the New York State Nurses Association, Volume 48, Number 1 by New York State Nurses Association

THE

JOURNAL of the New York State Nurses Association

Volume 48, Number 1

n E ditorial: The Many Roles of Nurses

by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, ACNS-BC; Meredith KingJensen, PhD, MSN, RN; Caroline Mosca, PhD, MSN, RN, ANP; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

ffects of an Online Education Program on Nurses’ Knowledge Concerning Advance Directives n Eand the Compliance Rate of Advance Directives by Chin K. Yoo, DNP, RN, CCM

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, and Lucille Contreras Sollazzo, MSN, RN-BC, NPD Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During n N theurses COVID-19 Pandemic, Part 3 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina DeGaray, MPH, RN-BC

n Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

by Marcelina Stewart, MSN, APRN, AGNP-C, and Marie Cox, DNP, RN, ANP-C

n Impact of Sleep on Nursing Students in the Era of a Pandemic

Marilyn B. Klainberg, EdD, RN, NYAM Fellow; Maureen C. Roller, DNP, RN, ANP-BC; Deborah AmbrosioMawhirter, EdD, RN, NYAM Fellow; Jacqueline P. Johnston, PhD, RN, ANP-C; Clarilee Hauser, PhD, RN; R. David Parker, PhD; and Susan M. Neville, PhD, RN, CDP, CADDCT, AACN Wharton Fellow

n What’s New in Healthcare Literature Activities: A Time-Limited Look at Whether the New York State Felony D Law or Workplace n CE Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting; Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

THE

JOURNAL of the New York State Nurses Association

Volume 48, Number 1

n E ditorial: The Many Roles of Nurses .................................................................................................................. 3 by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP,

ACNS-BC; Meredith King-Jensen, PhD, MSN, RN; Caroline Mosca, PhD, MSN, RN, ANP; and Coreen Simmons, PhD-c, DNP, MSN, MPH, RN

n Effects of an Online Education Program on Nurses’ Knowledge Concerning

Advance Directives and the Compliance Rate of Advance Directives................ 5 by Chin K. Yoo, DNP, RN, CCM

n A Time-Limited Look at Whether the New York State Felony D Law or

Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting.................................................................................................................................................................... 11 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, and Lucille Contreras Sollazzo, MSN, RN-BC, NPD

n Nurses Unions Can Help Reduce Stress, Burnout, Depression, and

Compassion Fatigue During the COVID-19 Pandemic, Part 3..................................... 30 by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD; and Christina DeGaray, MPH, RN-BC

n Barriers Impacting the Nurse Practitioner in Combating the

Opioid Epidemic.......................................................................................................................................................................... 52 by Marcelina Stewart, MSN, APRN, AGNP-C, and Marie Cox, DNP, RN, ANP-C

n Impact of Sleep on Nursing Students in the Era of a Pandemic................................ 57 Marilyn B. Klainberg, EdD, RN, NYAM Fellow; Maureen C. Roller, DNP, RN,

ANP-BC; Deborah Ambrosio-Mawhirter, EdD, RN, NYAM Fellow; Jacqueline P. Johnston, PhD, RN, ANP-C; Clarilee Hauser, PhD, RN; R. David Parker, PhD; and Susan M. Neville, PhD, RN, CDP, CADDCT, AACN Wharton Fellow

n What’s New in Healthcare Literature............................................................................................................... 64 n CE Activities: A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting; Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic ......................................................................................................................... 69

THE

JOURNAL

of the New York State Nurses Association

The Journal of the New York State Nurses Association Editorial Board

Audrey Graham-O’Gilvie, DNP, ACNS-BC Assistant Professor Touro College School of Nursing Hawthorne, NY Meredith King-Jensen, PhD, MSN, RN Quality Management Specialist Veteran’s Administration Bronx, NY Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Professional Nursing Practice Coordinator Teaneck, NJ

Anne Bové, MSN, RN-BC, CCRN, ANP Clinical Instructor New York, NY

Caroline Mosca, PhD, MSN, RN, ANP Faculty Program Director – Team Lead BS/MS Nursing Program Excelsior College Albany, NY

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor David Gray, Editorial Assistant The information, views, and opinions expressed in The Journal articles are those of the authors and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained. The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers. The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

Journal of the New York State Nurses Association, Volume 48, Number 1

n EDITORIAL The Many Roles of Nurses Everyone holds a unique role and place in their community through personal relationships: friend, child, parent, nurse. These change over the course of a lifetime; certain roles yielding their place to others. It is an understatement to say that current events have shaped the roles we play, often accentuating hidden talents and strength. In “A Time-Limited Look at Whether the New York State Felony D Law and Regulatory Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting,” the authors conclude that the law is not adequately effective in mitigating workplace violence and that programs tailored to the specific needs of healthcare organizations will be most effective in reducing the frequency and severity of violent incidents. The authors recognize that a paradigm shift in perceptions, responses, and standards comparable to that which occurred with domestic violence over the past generation is called for with regard to workplace violence. While many have themselves been unfortunate victims, nurses, working collectively and mindfully, are moving the tide toward safer and more just workplaces. In “Effects of an Online Education Program on Nurses’ Knowledge Concerning Advance Directives and the Compliance Rate of Advance Directives,” the author found that education improved nurses’ knowledge, empowering them to inform patients about their rights to complete advance directives. The role of nurses in this critical task transcends time and circumstance, as it serves to prompt formative conversations with patients about being prepared for future life events. In “Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic: Part 3,” the authors surveyed nurses’ experiences during the first wave of guided “real-time” COVID-19 practice changes, and found that several strategies, such as deploying team nursing, were effective in decreasing stress, improving patient care, and facilitating nurse competency. Team nursing was especially helpful for many who had never cared for ventilated patients or considered themselves “ICU nurses,” but who found themselves unexpectedly floated to areas where they had to care for the sickest patients in the world. The report also revealed how colleagues transformed the discomfort of their changed roles into opportunities for personal and professional growth as they stepped up to serve patients under extraordinary circumstances in a time of crisis. The role of the nurse practitioner as a key change agent in the battle against opioid substance use disorder and the epidemic’s related deaths is discussed in “Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic,” a study that makes the case for nurses as communicators, prescribers, and patient advocates. In 2020, the World Health Organization’s “Year of the Nurse,” the COVID-19 pandemic shone a spotlight on the essential roles nurses—like no other healthcare professional, and indeed no other group of people—play in society. Through the most personal and consequential of life’s events, nurses courageously and continuously adapt our roles as we care, not just for our patients, but our society as a whole. Meredith King-Jensen, PhD, MSN, RN Caroline Mosca, PhD, MSN, RN, ANP Coreen Simmons, PhD-c, DNP, MSN, MPH, RN Audrey Graham-O’Gilvie, DNP, ACNS-BC Anne Bové, MSN, RN-BC, CCRN, ANP

Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge Concerning Advance Directives and the Compliance Rate of Advance Directives Chin K. Yoo, DNP, RN, CCM

Acknowledgements I would like to take this opportunity to express my sincere thanks and deep gratitude to the host research hospital for allowing me to conduct my research study and to those who participated in the study. I also would like to extend my sincere thanks to Dr. Soundarapandian Vijayakumar for his assistance and time with data collection and analysis to complete the study.

n A bstract The purpose of this study was to evaluate the impact of an online education program on nurses’ knowledge on advance directives (ADs) and the compliance rate of advance directives in the medical records. This was a quasi-experimental comparative and descriptive prospective study using a voluntary convenience sample of registered nurses at the host research hospital and medical records review. Pre- and post-online education program data were collected using the Knowledge-Attitudinal-Experimental Survey on Advance Directives (KAESAD) tool (Jezewski, 2012) to assess the nurses’ knowledge on ADs. A total of 702 medical records on the medical-surgical units at the host research hospital were reviewed before and after the AD online education implementation to examine the compliance rates of ADs. There was an overall improvement of nurses’ knowledge of ADs and the compliance rates of ADs after the online education implementation. However, the improvement in the general knowledge of ADs category was not statistically significant. The results of this study warrants registered nurses’ further education on general knowledge of ADs. Keywords: advance directives, nurses’ knowledge, online education, compliance rate

Nurses’ Knowledge on Advance Directives Advance directives (ADs) document the individual’s wishes about the specific treatments they want or do not want for medical conditions, when they are unable to communicate their wishes. There are different types of advance directives. A living will documents an individual’s wish whether to receive certain medical treatments or not. A durable power of attorney for

health care (not recognized in New York State) requires designating a person to act as an agent who will make the decisions about medical treatments when the individual is unable to act on their own behalf (Cohen & Nirenberg, 2011). Americans are living longer with multiple chronic illnesses. Researchers Fox and Reichard (2013) stated that 53% of Americans between the ages of 18 to 64 years old and 74% of those over 65 years old have more than one

Chin K. Yoo, DNP, RN, CCM Corporate Denial Management Department, Nuvance Health System Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge

The need for better healthcare provider and patient understanding of end-of-life decision-making is greater than ever.

chronic illness. The need for better healthcare provider and patient understanding of end-of-life decision-making is greater than ever. Due to ongoing research and scientific advancements in health care, end-of-life care treatment options have changed and now require more thoughtful decision-making in regard to one’s medical care. Therefore, it is essential for healthcare providers to assist individuals in completing an AD, so that an individual’s wishes about their end-of-life care will be honored, fostering patient-centered care. The Patient Self-Determination Act (PSDA) was executed in 1991, and legally mandates healthcare organizations that participate in the Medicare and Medicaid programs to inform patients of their right to have an AD (Ryan & Jezewski, 2012). Even though the implementation of ADs is mandated, the process to complete an AD is not clearly defined. Healthcare providers should consider taking a more active role in assisting individuals in completing ADs, as this intervention can be considered a preventive health intervention since it provides information for future healthcare providers (Payne at al., 2010). Despite the enactment of the PSDA, the completion rate of ADs for patients in the United States is less than 30% (Hinders, 2012). The American Nurses Association (ANA) has affirmed the position of professional nursing in regards to the PSDA through its position statement on ADs (American Nurses Association, 2016), which supports the idea that nurses need knowledge, skills, and resources to facilitate the advance care planning process. The position statement indicated that education would be helpful in encouraging nurses to be proactive in discussing ADs with patients (Duke & Thompson, 2007). Supporting the need for nursing education on the topic of ADs, a study conducted by researchers Ryan and Jezewski (2012) found that the nurses scored 60% on the overall knowledge of ADs. This low knowledge score showed that the nurses had a belowstandard level of understanding of ADs. The study recommended more education regarding knowledge of ADs for nurses. Nurses’ involvement in educating and completing ADs is recommended because nurses are the most appropriate healthcare professionals to provide information and discuss ADs with patients (Hinders, 2012). Additionally, nurses are one of the key players in outcomes affecting low AD compliance rates. However, nurses must first become more knowledgeable on this topic through continued education. The purpose of the study is to evaluate the impact of an online education program on nurses’ knowledge concerning ADs and the compliance rate of ADs in the medical records at the host research hospital, one acute care teaching hospital located in the Northeastern United States.

keywords (a) advance directives, (b) nurse’s knowledge and confidence, and (c) end-of-life care to find articles from between 2005 and 2015. Some older articles were also reviewed because there were minimal studies available within the targeted five-year period.

Advance Directives The use of ADs has been legally in affect since 1991, when Congress (Ryan & Jezewski, 2012) passed the Patient Self-Determination Act (PSDA) of 1990. ADs are legal documents representing patients’ wishes about their end-of-life care treatments. The purpose of ADs is to provide early communication about an individual’s end-of-life care decisions before they are no longer able to make them. Evidence supports that developing an AD reduces the burden of difficult decisions for the patient’s family as the patient nears their end-of-life (Cohen & Nirenberg, 2011). In today’s healthcare delivery system, the end-of-life care decision process has been changed and is more complicated due to technological, economical, and societal advancements (Watson, 2010). According to U.S. Census Bureau data, more than 20% of U.S. residents are projected to be aged 65 and over by 2030, compared with 13% in 2010 (Ortman et al., 2014). At present, the majority of elderly people have at least one chronic medical condition and some elderly people have multiple medical conditions (Hinders, 2012). The current healthcare system is focused on cure and technology, while patients’ preferences about their end-of-life treatments are often misunderstood or ignored (Woytkiw, 2010). The completion rate of ADs remains disappointing, despite ongoing efforts to encourage their use. Evidence is building that concludes conversations between healthcare providers and patients about ADs is not happening during hospitalization (Salmond & David, 2005; Walling et al., 2010).

Nurses’ Role Nurses work closely with patients and are available to discuss endof-life care. Nurses should play a role as a patient advocate to ensure that patients are informed about their rights to complete ADs (PutnamCasdorph et al., 2008). A qualitative study by Boot and Wilson (2014) reported that clinical nurse specialists had to determine the risk of causing harm to patients by not discussing ADs, as well as the risk of initiating the discussion about ADs with patients who may not be ready. Similarly, research findings support that the patients who have a good understanding of ADs were not always involved in discussions about end-of-life care with their nurses (Simon et al., 2008; Almack et al., 2012).

Nurses’ Knowledge

Literature Review

Ryan and Jezewski (2012) conducted a systematic synthesis of three studies on the knowledge, attitudes, experiences, and confidence of nurses in completing ADs. Their review showed that the nurses’ level of knowledge about ADs was at a level of 60% and nurses had a moderate level of confidence with regard to ADs. Nurses reported that they had experiences with discussing ADs and expressed positive attitudes about completing ADs.

CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Medline were searched for research journal articles and peer-reviewed journals and books. These sources were searched using the following

The research studies were conducted on nurses in various specialties in acute hospital settings to evaluate their knowledge, attitude, and confidence regarding ADs. Oncology is one of the very specialized fields in the healthcare

Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge

system. Since the majority of the oncology patients require treatments for a certain period of time and occasional inpatient hospitalization, oncology nurses are able to build a relationship with their patients. For this reason, oncology nurses, more than any other healthcare providers, are in a place to educate and discuss end-of-life care and decisions. The research study by Jezewski et al. (2005) demonstrated that oncology nurses were most knowledgeable about ADs, but were not knowledgeable about the PSDA or their state laws. Oncology nurses strongly agreed that they should be patient advocates and inform them about their conditions and treatment alternatives. Overall, oncology nurses with more knowledge and experience had more positive attitudes regarding ADs, but responded that they did not have enough time to discuss ADs with patients. Emergency department (ED) nurses also work in a specialized care setting. According to the research studies by Jezewski and Meeker (2005) and Jezewski et al. (2007), the findings were somewhat similar to the study with oncology nurses. ED nurses felt that they lacked an understanding of the PSDA, ADs, and their state laws. They also agreed that they did not have sufficient time to discuss ADs with patients. However, the ED nurses had low scores on the general knowledge of ADs. Unlike most researchers, belief that the role of advocacy should be part of a nurse’s responsibility regarding ADs was not shared by ED nurses; they did not believe that their role was to assist with the completion of ADs for the patients who were admitted to the ED (Jezewski & Meeker, 2005).

Education Nursing students at a state university in Minnesota participated in a study evaluating the effectiveness of education by completing their own ADs (Hall & Grant, 2014). The students received this learning activity positively. The findings of this study provided support for incorporation of this activity in academic and practice settings and for future research (Hall & Grant, 2014). A quasi-experimental pilot study (Hinderer & Lee, 2014) assessed the effectiveness of a nurse-led educational AD seminar. The study reported that 97% of the participants stated that the seminar was helpful and they were likely to complete an AD. They also stated that they would discuss ADs with their family or friends. A systematic review was completed to analyze the outcome of newly completed ADs, focusing on the effectiveness of the number of educational interventions provided (Durbin et al., 2010). This review found that the type of educational intervention made no difference in the rate of completion of new ADs (Durbin et al., 2010). Flowers and Howe (2015) found that the development of a training program to increase understanding and awareness of ADs resulted in positive outcomes. Participants experienced that the training helped to motivate them to have conversations with older family members and helped them to facilitate conversations about end-of-life care. Twenty-five percent of participants stated that they would be utilizing the information during their end-of-life care discussion with patients.

Method This research study was conducted between October 2017 and February 2018 at the host research hospital. The host research hospital is

a 300-bed community teaching hospital located in Danbury, Connecticut. A quasi-experimental comparative design was used to evaluate the nurses’ knowledge on ADs. A descriptive prospective design was used for the medical record reviews. A voluntary convenience sample of registered nurses (RNs) at the host research hospital served as the research subjects. The subjects were recruited by emails and announcements from their nursing supervisors and managers. There were no exclusion criteria for the research subjects. They were administered an online informed consent form before they participated in the online education program. The researcher developed the online education program on ADs based on the the host research hospital palliative care education materials that included legal references regarding ADs. The informed consent form, the online education program, the pre-test, and the two post-tests were uploaded into the HealthStream online learning site at the host research hospital. Over five consecutive days, the researcher conducted a medical records review of the patients who were admitted to eight medical-surgical units (excluding intensive care units [ICUs], maternity, and pediatric units) to identify the presence of completed ADs in the medical records. Then, the RNs were requested to complete an online informed consent form in order for them to participate in the online education intervention program in the following 3-week period. The RNs who consented to the study were administered the pre-test, the online education program on ADs, and the post-test immediately after completion of the online education intervention program. A second post-test was initiated three weeks later to measure participants’ knowledge retention. Additionally, the primary investigator (CY) conducted another medical records review in the same manner as the first medical charts review over five consecutive days following the participants’ completion of the online education program.

Instrument To assess the nurses’ knowledge of ADs, the pre-test and post-test were derived from the instrument called the Knowledge-Attitudinal-Experimental Survey on Advance Directives (KAESAD). The KAESAD (Jezewski, 2005) was developed to measure nurses’ knowledge of, attitude toward, and experiences with ADs in end-of-life decisions. The KAESAD contains a total of 115 questions in five domains and has a reported Cronbach’s alpha ranging from 0.52–0.95 (Ryan & Jezewski, 2012). The primary investigator used 30 of the 115 questions that were specific to the overall knowledge of ADs for this study. The 30 questions consisted of 10 general knowledge questions about ADs, seven questions on the PSDA, and 13 questions on state laws (California, Illinois, New York, and Texas). The primary investigator did not change the wording of the questions concerning the state laws, although this instrument did not have the questions specifically for Connecticut State law. Participants were asked to check one of three possible answers for each question: “true,” “false,” or “don’t know.”

Results A total of 122 RNs consented to participate in the study and completed the pre-test. However, 117 RNs completed the post-test immediately following the completion of the online education program, and only 61 RNs returned to take the post-test 3 weeks after the completion of the online education intervention program.

Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge

Table 1 Nurses’ Knowledge on ADs

Mean score

General knowledge

PSDA

State law

Overall knowledge

Pre-test

68.3%

54.0%

66.9%

64.1%

Immediate post-test

72.9%

60.5%

83.1%

74.7%

3-week post-test

69.9%

58.6%

76.9%

71.0%

Nurses’ Knowledge on Advance Directives A paired two-tail t-test was used to measure the nurses’ knowledge regarding ADs. The data were analyzed between the pre-test and immediate post-test and the pre-test and 3-week post-test. The nurses’ knowledge on ADs were assessed in the three categories of the KAESAD: general knowledge of ADs, knowledge of the PSDA, and knowledge of the state law.

Pre-Test and Immediate Post-Test Participants demonstrated an overall improvement on the survey as a whole using the total 30 questions. The improvement on the overall knowledge of ADs was statistically significant (p = 0.030). However, within the three categories of questions, only two categories showed statistical significance: knowledge of the PSDA (p = 0.012) and the state law (p = 0.004). The first category, general knowledge of ADs, did not show statistical significance (p = 0.740).

Pre-Test and 3-Week Post-Test The improvement of the overall knowledge of ADs three weeks after the intervention wasn’t statistically significant (p = 0.146). However, knowledge of the PSDA (p = 0.024) and the state law (p = 0.017) categories remained statistically significant, whereas the improvement of general knowledge of ADs category was not statistically significant (p = 0.910) (see Table 1).

Compliance Rate of Advance Directives A total of 702 medical records were reviewed during the first and second reviews. The first medical records review was conducted before the implementation of the online education intervention program and the second medical records review was completed after the online education

Table 2 The Compliance Rates of the ADs

Medical records review #1

Medical records review #2

Yes

312

376

Total

317

385

Compliance rate

1.6%

2.3%

intervention program was provided to the RNs. For the first review, 5 out 317 medical records had completed ADs. For the second review, 9 out of 385 medical records had completed ADs. The compliance rates of the ADs were analyzed with 95% CI [0.2221– 2.0184] and z value of 0.713. The compliance rate of ADs improved from the first medical records review to the second medical records review. However, the improvement of the compliance rates was not statistically significant (p = 0.476) (see Table 2).

Conclusion The RNs who participated in the study showed improvement in the overall knowledge of ADs before (64%) and after (75% and 71%) the implementation of the online education program based on the mean scores of the three categories of the KAESAD instrument. The RNs at the host research hospital scored better than the group of nurses previously studied by Ryan and Jezewski (2012), in which test score results were 60% on overall knowledge of ADs. The mean scores of the knowledge of the PSDA before (54%) and after (61% and 59%) the implementation of the online education program were also better than the mean scores (51%) from the previous study (Ryan & Jezewski, 2012). The mean scores of the state law wouldn’t be compatible with the scores of the previous study (Ryan & Jezewski, 2012), because the original instrument didn’t include questions regarding the state law. Interestingly, the mean scores of all three categories of the KAESAD and the overall knowledge of the ADs before and after the implementation of the online education intervention program were improved. However, there was a discrepancy in the statistical significance on the overall knowledge improvement between the pre-test and immediate post-test and pre-test and 3-week post-test. This discrepancy occurred because the improvement of the general knowledge of ADs didn’t show statistically significant difference between pre-test and immediate post-test and pretest and 3-week post-test. The compliance rate of ADs in the medical records was slightly improved after the implementation of the online education program, however, the increase was not statistically significant. Overall, this study demonstrated that the online education program on ADs improved nurses’ knowledge and the compliance rate, but not enough to show sufficient statistical significance. The findings of this study also suggested that nurses played a role in the improvement of the compliance rate of ADs.

Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge

Therefore, future studies should continue to focus on education for nurses. Educational information specific to general knowledge of ADs is necessary and may need further enhancement for this online program, since the improvement of the general knowledge of ADs wasn’t statistically significant. In addition, more education on the knowledge of the PSDA should be considered due to low mean scores. Another suggestion to enhance future studies may be to allow for a longer interval from the pre-

test to the post-test, as only 50% of the participants who completed the pre-test returned to take the post-test. An increase in the time interval may improve the participation of the RNs who completed the pre-test to return to take the post-test, which can possibly make the outcome more statistically significant. Other future studies should examine the barriers to the low compliance rate of ADs.

Journal of the New York State Nurses Association, Volume 48, Number 1

Effects of an Online Education Program on Nurses’ Knowledge

n References Almack, K., Cox, K., Moghaddam, N., Pollock, K., & Seymour, J. (2012). After you: Conversations between patients and healthcare professionals in planning for end-of-life care. BMC Palliative Care, 11, 15.

Jezewski, M. A., Finnell, D. S., Yow-Wu, B. W., Meeker, M. A., Sessanna, L., & Lee, J. (2009).Psychometric testing of four transtheoretical model questionnaires for the behavior, completing health care proxies. Research of Nursing and Health, 32, 606–620.

American Nurses Association. (2016). Nurses’ Roles and Responsibilities in Providing Care and Support at the End of Life. https://www. nursingworld.org/~4af078/globalassets/docs/ana/ethics/endoflifepositionstatement.pdf

Jezewski, M. A., & Meeker, M. A. (2005). What is needed to assist patients with advance directives from the perspective of emergency nurses. Journal of Emergency Nursing, 31(2), 150–155.

Boot, M., & Wilson, C. (2014). Clinical nurse specialists’ perspectives on advance care planning conversations: A qualitative study. International Journal of Palliative Nursing, 20(1), 9–14. Cohen, A., & Nirenbereg, A. (2011). Current practices in advance care planning: Implications for oncology nurses. Clinical Journal of Oncology Nursing, 15(5), 547–553. Duke, G., & Thompson, S. (2007). Knowledge, attitudes, and practices of nursing personnel regarding advance directives. Interventional Journal of Palliative Nursing, 13, 109–115. Durbin, C. R., Fish, A. F., Bachman, J. A., & Smith, K. V. (2010). Systematic review of educational interventions for improving advance directive completion. Journal of Nursing Scholarship, 42(3), 234–241. Flowers, K., & Howe, J. L. (2015). Educating aging service agency staff about discussing end-of-life wishes. Journal of Social Work in Endof-life & Palliative Care, 11(2), 147–166. Fox, M. H., & Reichard, A. (2013). Disability, health, and multiple chronic conditions among people eligible for both Medicare and Medicaid, 2005–2010. http://www.cdc.gov/pcd/issues/2013/13_0064.htm Hall, N. A., & Grant, M. (2014). Completing advance directives as a learning activity. Journal of Hospice & Palliative Nursing, 16(6), 150–157.

Ortman, J. A., Velkoff, V. A., & Hogan, H. (2010). An aging nation: The older population in the United States. http://www.census.gov/ prod/2014pubs/p25-1140.pdf Payne, K. L., Prentice-Dunn, S., & Allen, R. S. (2010). A comparison of two interventions to increase completion of advance directives. Clinical Gerontologist, 33, 49–61. Putnam-Casdorph, H., Drenning, C., Richards, S., & Messenger, K. (2008). Advance directives evaluation of nurses’ knowledge, attitude, confidence, and experience. Journal of Nursing Care Quality, 24(3), 250–256. Ryan, D., & Jezewski, M. A. (2012). Knowledge, experiences, and confidence of nurses in completing advance directives: A systematic synthesis of three studies. The Journal of Nursing Research, 20(2), 131–140. Salmond, S. W., & David, E. (2005). Attitudes toward advance directives and advance directive completion rates. Orthopedic Nursing, 24(2), 117–127. Simon, J., Murray, A., & Raffin, S. (2008). Facilitated advance care planning: What is the patient experience? Journal of Palliative Care, 24(4), 256–264.

Hinderer, K. A., & Lee, M. C. (2014). Assessing a nurse-led advance directive and advance care planning seminar. Applied Nursing Research, 27, 84–86.

Walling, A. M., Asch, S. M., Lorenz, K. A., Roth, C. P., Baery, T., Kahn, K. L., & Wenger, N. S. (2010). The quality of care provided to hospitalized patients at the end of life. Archives of Internal Medicine, 170, 1057–1063.

Hinders, D. (2012). Advance directives: Limitations to completion. American Journal of Hospice & Palliative Medicine, 29(4), 286–289.

Watson, E. (2010). Advance directives: Self-determination, legislation, and litigation issues. Journal of Legal Nurse Consulting, 21(4), 9–14.

Jezewski, M. A., Brown, J. K., Wu, Y. B., Meeker, M. A., Feng, J. Y., & Bu, X. (2005). Oncology nurses’ knowledge, attitudes, and experiences regarding advance directives. Oncology Nursing Forum, 32(2), 319–327.

Woytkiw, T. D. (2010). Advance care planning: Making the best choice for the future. Canadian Nursing Home, 21(3), 13–17.

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, MSN, RN-BC, NPD

n A bstract

A hospital setting creates extreme levels of stress for patients, their families, and for the nurses who treat and interact with those individuals. Fear, illness, long wait times, and loss of control are major contributors to agitation and aggression from patients and families. Workplace violence in health care is an important public health issue and a growing concern. Workers in the healthcare industry experience the highest rates of injuries due to workplace violence and are five times as likely to suffer an injury due to workplace violence than other workers overall. In 2006, New York State (NYS) enacted legislation requiring public employers to develop and implement programs to prevent and minimize workplace violence and help ensure the safety of public-sector employees. The Occupational Safety and Health Act (OSHA) compiled a suite of resources to help build and implement a voluntary, comprehensive workplace violence program in private healthcare facilities. In 2010, the NYS Senate passed legislation strengthening the penalties for individuals who injure or attempt to injure nurses while the nurse is practicing in the line of duty. The Felony D law imposes a penalty for assault on registered nurses (RNs) as a class D felony. This article takes a time-limited look at whether the NYS Felony D law and regulatory anti-workplace violence programs thus far mitigate the incidences of violence against nurses in the workplace. Keywords: Felony D law, workplace violence, hospitals, nurses

Introduction Definitions of Workplace Violence

 Type II involves a customer, client, or patient. In this type, an “individual has a relationship with the business and becomes violent while receiving services.”

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence (WPV) as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” (NIOSH, 2014). NIOSH classifies workplace violence into four basic types. Types II and III are the most common in the healthcare industry.

 Type III violence involves a “worker-on-worker” relationship and includes “employees who attack or threaten another employee.”  Type IV violence involves personal relationships. It includes “individuals who have interpersonal relationships with the intended target but no relationship to the business.”

 Type I involves “criminal intent.” In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its employees.”

The World Health Organization (WHO) defines workplace violence as “incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an

Lucille Contreras Sollazzo, MSN, RN-BC, NPD, and Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Nursing Education and Practice, New York State Nurses Association Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Currently, there is no specific federal statute that requires workplace violence protections in the healthcare industry.

explicit or implicit challenge to their safety, well-being, or health” (WHO, 2002). The American Nurses Association (ANA) describes workplace violence as physically and psychologically damaging actions that occur in the workplace or while on duty and includes lateral violence (acts between colleagues, bullying, hostility, abuse of authority, and sexual harassment) in their definition of WPV (American Nurses Association, 2019). Some examples of WPV include direct physical assaults (biting, scratching, shoving, hitting, or spitting) (with or without weapons), written or verbal threats, physical or verbal harassment (yelling, screaming), and homicide.

Federal Laws Addressing Workplace Violence Currently, there is no specific federal statute that requires workplace violence protections in the healthcare industry. OSHA does not require employers to implement workplace violence prevention programs, but it provides voluntary and recommended guidelines healthcare organizations can implement and may cite employers for failing to provide a workplace “free from recognized serious hazards” (The General Duty Clause, Section 5(a)(1) of the Occupational Safety and Health Act). Additionally, when the criteria for an OSHA citation are not met by a healthcare worker who files a complaint, inspectors may issue warnings known as “hazard alert letters.” However, employers are not required to take corrective action in response to them, and OSHA does not require inspectors to follow up to see if employers have taken corrective actions. As a result, OSHA does not know whether identified hazards have been addressed and hazards may therefore continuously persist. Indeed, at no time has OSHA fully assessed the results of its efforts to address workplace violence in healthcare facilities. Without assessing these results, OSHA is not in a position to know whether its efforts are effective or if additional actions may be needed to address a hazard. (U.S. Government of Accountability Office [GAO], 2016). The Joint Commission Standard LD.03.01.01 (a voluntary standard that healthcare organizations can implement) requires healthcare leaders to create and maintain a culture of safety and quality throughout the organization. The Joint Commission Standard §A4 requires healthcare leaders to develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety, and §A5 requires leaders to create and implement a process for managing behaviors that undermine a culture of safety (Joint Commission, 2018). These standards are applicable to ambulatory care, critical access hospital, home care, hospital, laboratory, long-term care, Medicare and Medicaid, certificationbased long-term care, and office-based surgery programs and behavioral healthcare programs. Recognizing that within the private industry, healthcare workers are five times more likely than workers in other industries to experience incidences of workplace violence that require days off for the injured worker to recover (GAO, 2016), federal legislation H.R. 1309 was proposed in June 2019. If enacted, The Workplace Violence Prevention for Health Care and Social Service Workers 12

Act would require the OSHA to establish an interim standard within 1 year, a proposed standard within 2 years, and a final standard within 4 years. The bill also would amend the Social Security Act to require facilities to comply with the standard if they receive Medicare funds but do not otherwise fall under OSHA’s authority. The proposed act would (Burdick, 2019):  Require OSHA to create a federal workplace violence prevention standard mandating that employers develop comprehensive, workplace-specific plans to prevent violence.  Cover a wide variety of workplaces, including hospitals and other inpatient facilities, residential and non-residential treatment settings, medical treatment or social service settings, psychiatric and behavioral health settings, community care setting, and field work settings. More specifically, the proposed law would mandate a standard that applied to all hospitals and medical treatment centers; clinics at correctional facilities; group homes, mental health clinics, psychiatric treatment facilities, drug and alcohol addiction treatment facilities; and freestanding emergency centers. Covered social services would include emergency medical and fire services, home-based social work and field services, and home health care and home-based hospice care.  Set a quick timeline on implementation to ensure timely protection for healthcare workers.  Set minimum requirements for the standard and for employers’ workplace violence prevention plans. These requirements include unit-specific assessments and implementation of prevention measures such as physical changes to the environment; staffing for patient care and security; employee involvement in all steps of the plan; hands-on training; record keeping requirements, including a violent incident log; and protections for employees to report workplace violence to their employers and law enforcement officials. Requirements of a final standard would include:  written workplace violence prevention plans, developed with employee participation, covering hazard prevention, incident response, reporting, and post-incident investigation procedures;  emergency response procedures, including procedures for mass-casualty incidents and incidents involving firearms or weapons;  training and education for covered employees;  violent incident logs and records of hazard assessments and employee training;  an annual summary of each logged violent incident and a report submitted each February 15 to OSHA; and  an annual evaluation of the employer workplace violence prevention program (WVPP) with the participation of covered employees and their representatives.

New York State Laws Addressing Workplace Violence For public-sector employees, New York State has enacted legislation and regulations aimed at protecting healthcare workers from the effects of workplace violence. In 2006, the New York State Department of Labor

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

(NYSDOL) enacted legislation requiring public-sector healthcare employers to develop and implement programs to prevent and minimize workplace violence and help ensure the safety of public-sector healthcare employees. The Public Employee Safety and Health (PESH) Bureau developed a How to Comply Guide to assist New York public-sector healthcare employers in complying with the regulations. Essentially, employers must do the following (NYS Department of Labor, n.d.): 1. Develop and post a written policy statement about the employer’s WVPP goals and objectives. 2. Conduct a risk evaluation by examining the workplace for potential hazards related to workplace violence with an authorized employee representative (if there is one). 3. Develop a WVPP (in writing, although that is only required for employers with 20 or more full-time permanent employees) that explains how the policy is actually going to be implemented. The program will include details about the risks that were identified in the basic evaluation and describe how the employer will address those risks. It will also include a system to report any incidents of workplace violence, among other things. 4. Provide training and information for employees around the WVPP, including any risk factors identified and what employees can do to protect themselves. 5. Document workplace violence incidents and maintain those records. 6. Annually review all workplace violence incidences with an authorized employee representative (if there is one) to determine what, if any, changes need to be made to the program or identified risk factors. In 2010, New York State implemented the Violence Against Nurses law, making it a felony to assault an on-duty RN. At the time, New York was addressing a commonly held, inappropriate, and erroneous belief that dealing with violent or abusive patients and caregivers was considered part of the job. The New York State Senate passed the legislation noting that, according to the U.S. Department of Justice, nearly 500,000 nurses each year become victims of violent crimes in the workplace. Engaging in an assault against an RN on duty is a Class D felony, subject to a maximum of seven years in prison.

New York State Bills Addressing Workplace Violence In 2010, the New York State Senate passed S1823B, which would have created a private cause of action for employees who have been

In 2018, the U.S. Bureau of Labor Statistics (BLS) reported that the healthcare industry experiences the highest rate of injuries caused by workplace violence and that healthcare workers are five times as likely to suffer a workplace violence injury than the workers of all other industries overall.

harmed psychologically, physically, or economically because of an abusive workplace. The proposed bill would have made it unlawful to “[s]ubject an employee to an abusive work environment.” An employer would have been “[c]ivilly liable for the existence of an abusive work environment within any workplace under its control.” The bill defined an abusive work environment as “[a] workplace in which an employee is subjected to abusive conduct that is so severe that it causes physical or psychological harm.” The bill was not passed by the New York State Assembly and is, therefore, not current law. Every year since 2006, New York State legislators have introduced different versions of this “anti-bullying in the workplace” bill, commonly known as the Healthy Workplace Bill, but it has yet to pass in both houses.

Questions Presented This study reviews the various measures that have been implemented in New York State to mitigate and prevent workplace violence in healthcare settings to determine the following: 1. Do current federal and state laws, regulations, and guidance significantly reduce the incidences of workplace violence against nurses in New York healthcare settings? 2. Are there any other measures that can be taken by a union that significantly reduces the incidences of workplace violence against nurses in healthcare settings?

Literature Review The Extent of the Problem There are approximately 3 million RNs who are working in the United States across all industries. There are approximately a total of 188,000 active RNs practicing statewide in New York State (Harun et al., 2016). Research has documented that many RNs face varied workplace hazards while performing their routine duties (U.S. Bureau of Labor Statistics [BLS], 2018a). In 2018, the U.S. Bureau of Labor Statistics (BLS) reported that the healthcare industry experiences the highest rate of injuries caused by workplace violence and that healthcare workers are five times as likely to suffer a workplace violence injury than the workers of all other industries overall (BLS, 2018a; GAO, 2016). Patient violence towards hospital workers that does not result in physical injury, but can result in psychological injury, includes spitting; verbal abuse, which involves another person yelling or swearing; engaging in name calling; or using other words intended to control or hurt. Such “non-physical” violence can have psychological effects, such as reduced work satisfaction, and sleep disorders, burnout, depression, and posttraumatic stress disorder. It can also lead to restricted or modified work, transfers, leaves of absence, and increases in employee turnover (Healthy Work Strategies, 2019). Severe physical and psychological injuries can lead to workers missing work or being assigned to restricted or modified duty. Collectively, the rate of such injuries is referred to as the Days Away, Restricted, or Transferred (DART) Rate. Indeed, workplace violence due to intentional injuries by other person(s) in the private healthcare industry accounted for 2% of the 900,380 total nonfatal occupational injuries or illness cases requiring days away from work in 2018 (U.S. Bureau of Labor Statistics

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 1 Incidence Rate of Nonfatal Workplace Violence to Healthcare Workers, 2011–18

Table 2 Number of Nonfatal Occupational Injuries and Illnesses Involving Days Away From Work Resulting From Intentional Injury by Other Person, in the Private Healthcare Industry, 2011–18

Year

Incidence rate (per 10,000 full-time workers)

2011

6.4

Year

2012

7.0

2011

8,180

3,510

2013

7.8

2012

9,170

3,610

2014

8.2

2013

10,450

3,350

Healthcare industry

Other industries

2015

8.0

2014

11,100

4,880

2016

8.4

2015

11,200

4,960

2017

9.1

2016

11,830

5,060

2018

10.4

2017

13,080

5,320

2018

15,230

5,560

Note: In 2018 in the private sector, the all-worker incidence rate for nonfatal occupational injuries and illnesses involving days away from work resulting from intentional injury by other person in the private healthcare settings was 10.4 per 10,000 full-time workers, compared to the all-worker incidence rate of 2.1 (BLS, 2018b).

Note: This data was last modified by the U.S. Bureau of Labor Statistics on April 8, 2020 (BLS, 2018b).

In 2018 in the public sector, the incidence rate of intentional injury for nonfatal cases involving days away from work in the healthcare industry was 13.9 per 10,000 full-time workers (1,050 cases) in local government, and 89.3 (4,850 cases) in state government. The all-worker incidence rate for cases involving days away from work for local government was 163.9 and for state government was 142.6 (BLS, 2018b).

Table 3 Incidences of Reported Intentional Nonfatal Injury by Person 2011–18

In the private sector in last decade (2008–17), the incidence of workplace violence increased 69% in the healthcare industry.

25,000

U.S. Bureau of Labor Statistics (2018a, 2018b)

20,000 15,000

[BLS], 2018b). According to the BLS, hospitals have a higher rate of “days away” cases than construction, manufacturing, or private industry as a whole (OSHA, 2013).

10,000

Reportedly, since 2011, the overall annual incidence rate for workplace violence to U.S. healthcare workers has increased (see Table 1).

5,000

It is a well-documented fact that in the United States, it is difficult to find accurate statistics relating to workplace violence in the healthcare industry due to substantial underreporting (Lebron, 2019). One study done in 2000 revealed that only 30% of nurses reported incidences of workplace violence (Duncan et al., 2000). Indeed, a study in Washington State found 90% of organizations surveyed were not complying with OSHA reporting regulations (Wuellner & Bonauto, 2014). This underreporting creates a misleading picture of violence in the workplace and—as a direct result of not acknowledging the issue—employers of healthcare organizations fail to adequately protect their employees (Lebron, 2020). Various reasons for underreporting are found in the literature, and they include: (a) fear of retaliation from the employer and/or colleague for reporting a situation; (b) fear of perception as being a “snitch,” “petty,” “judgmental,” and/or a “goodie-goodie” for reporting a situation and subsequently being ostracized by coworkers; (c) lack of policies and procedures for reporting incidences; (d) fear of lack of privacy and support for the making of a report; (e) lack of training and understanding

Journal of the New York State Nurses Association, Volume 48, Number 1

2011 2012 2013 2014 2015 2016 2017 2018 Reported injuries per year

New York RNs working in Downstate hospitals perceived a greater risk of on-the-job physical injury than Upstate RNs working in hospitals, and those working in public hospitals perceived a greater risk than those working in private hospitals.

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 3 (continued) Incidences of Reported Intentional Nonfatal Injury by Person 2011–18

Nonfatal injury by person—assault type

2011

2012

2013

2014

2015

2016

2017

2018

840

640

670

490

550

580

200

270

Shooting by other person, intentional

110

710

140

180

160

Stabbing, cutting, slashing, piercing

160

130

110

550

430

120

130

140

8,950

10,500

11,730

12,680

13,680

15,060

16,950

18,940

Strangulation by other person

120

110

Rape, sexual assult

Threat, verbal assault

290

310

210

240

130

110

220

430

Multiple violent acts by other person

200

170

370

190

Other

1,110

1,020

640

810

950

700

690

620

Total

11,690

12,780

13,810

15,980

16,160

16,890

18,370

20,790

Intentional injury by other person, unspecified

Hitting, kicking, beating, shoving

U.S. Bureau of Labor Statistics (2018a) on what workplace violence is and why it is important to report situations; (f) employers who maintain OSHA records do not fully understand what to record as a case, when to document a case, and how to classify the case in terms of severity; (g) employers erroneously do not maintain records on temporary and agency employees; (h) employers indicate that the filing of reports were overly burdensome; (i) employers encourage non-reporting; and (j) verbal incidences of violence are not reported and/or recorded (Copeland & Henry, 2017; Fagan & Hodgson, 2016; Fredrickson, 2020; Phillips, 2016; Wuellner & Bonauto, 2014).

Efficacy of Laws, Rules, and Guidance Promulgated to Mitigate Workplace Violence

By analyzing the source data from the BLS, it is possible to identify specific trends in workplace violence statistics in healthcare settings; however, even those statistics are flawed inasmuch as the BLS does not record verbal incidences of violence (Phillips, 2016). From 2011 to 2018, U.S. healthcare workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in the private healthcare industry (see Table 2 and 3).

Similarly, in 1998, the U.S. Supreme Court determined in Faragher v. City of Boca Raton that companies must prevent—not simply react to—a

The U.S. Bureau of Labor Statistics gives us a look at the incidences of reported fatal injuries by person in healthcare settings from 2011 to 2018, shown in Table 4. The healthcare industry is made up of a combination of various services and providers. A look at the various services components of the United States’ private healthcare industry in 2017 and 2018, along with their respective incidence rates, is shown below in Table 5. A study conducted by the New York Center for Health Workforce Studies (2008) determined that New York RNs working in Downstate hospitals perceived a greater risk of on-the-job physical injury than Upstate RNs working in hospitals, and those working in public hospitals perceived a greater risk than those working in private hospitals. Current practice areas were strongly related to perceptions of physical risk. Not surprisingly, the highest risk was perceived by RNs working in behavioral health and the emergency department. RNs working in oncology and palliative care/ hospice units perceived the lowest risk (see Table 6).

Research studies and surveys show violence against healthcare employees has increasingly risen over the years and is more common than most people realize. Advocacy groups say it’s time for policymakers and employers to act on this growing, but underreported problem. Indeed, some studies reported that even with regulatory initiatives, it is mostly the employer’s obligation to ensure a healthy, violence-free work environment (Hoel et al., n.d.; Itzhaki et al., 2018).

Table 4 Incidences of Reported Intentional Fatal Injuries by Person 2011–18 600 500 400 300 200 100 0

2011

2012

2013

2014

2015

2016

2017

2018

Reported injuries per year

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 4 (continued) Incidences of Reported Intentional Fatal Injuries by Person 2011–18

Fatal injury by person—assault type

2011

2012

2013

2014

2015

2016

2017

2018

Shooting by other person, intentional

365

381

322

307

354

394

351

Stabbing, cutting, slashing, piercing

Hitting, kicking, beating, shoving

450

461

393

395

411

483

441

439

Strangulation by other person Multiple violent acts by other person Total

Note: Of these 28,870 reported 2017 workplace violence events, 8,640 occurred in nursing and residential care facilities, 6,590 occurred in hospitals, and 2,370 in social assistance settings. Since 1992, workplace violence injury rates increased by 5%. The third leading cause of death for workers in the healthcare industries is workplace violence. U.S. Bureau of Labor Statistics (2018a)

Table 5 Incidence Rate of Nonfatal Intentional Injury by Other Person, Per 10,000 Full-Time Workers

Private industry

2017** Incidence rate of nonfatal intentional injury by other person, per 10,000 full-time workers

2018* Incidence rate of nonfatal intentional injury by other person, per 10,000 full-time workers

All Industry

2.9

2.1

Healthcare and social assistance

13.7

10.4

Ambulatory healthcare services

3.1

Hospitals

16.6

12.8

Psychiatric and substance abuse hospitals

181.1

124.9

Nursing and residential care facilities

33.4

21.1

Note: Since 2008, the workplace violence injury rate in private hospitals more than doubled, with the rate in psychiatric and substance abuse hospitals increasing by 158%. *AFL-CIO (2019) **U.S. Bureau of Labor Statistics (2018b)

hostile workplace. Thus, the Court articulated the concept of having “zero tolerance” for workplace violence, which focuses on how the employer will react once violence has occurred on its premises, is an insufficient approach that needs to evolve to the more progressive approach of “zero incidents,” which focuses on elimination of, “at risk,” behaviors before an incident occurs. While the number of federal OSHA inspections involving workplace violence in healthcare facilities has increased over the years, only a small percentage of these inspections resulted in general duty clause citations related to workplace violence. As described in OSHA’s enforcement directive, within the 6-month prescribed statute of limitations, to cite an employer for violating the general duty clause for a workplace violence hazard, OSHA inspectors must demonstrate that: (a) a serious workplace violence hazard exists and the employer failed to keep its workplace free of hazards to which employees were exposed, (b) the hazard is recognized by the employer or within the industry, (c) the hazard caused or is likely to 16

cause death or serious physical harm, and (d) there are feasible abatement methods to address the hazard. The U.S. Government of Accountability Office (GAO) (2016) reported that from 1991 through April 2015, OSHA issued only 18 general duty clause citations to healthcare employers for failing to address workplace violence. Seventeen of these citations were issued from 2010 through 2014 (see Table 7). These citations were issued in about 5% of the 344 workplace violence inspections of healthcare employers that were conducted from 1991 to April 2015 (GAO, 2016, p. 32). The NYSDOL is responsible for ensuring public healthcare employer compliance with regulatory workplace violence prevention requirements and issuing citations when the requirements are not followed. Similar to OSHA, the state agency, NYSDOL, oversight activities include investigating complaints and reports of violent incidents, as well as conducting planned inspections. The 2016 GAO report indicates that out of nine states with comparable state regulations from 2010 through

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 6 Perceptions of Physical Risk by Area of Practice 3.5

3.23

3.0

Table 7 2010–14 Number of OSHA Workplace Violence Inspections at Healthcare Facilities 100

3.08

2.5

2.70 2.69 2.62

2.46 2.38 2.34 2.31

2.22 2.21 2.20 2.18 2.17

2.0

86 3

80 2.10 2.04

1.90

71 6

67 4

1.5 40

Beh

avio

ra Em l healt erg h Adu ency d ept lt cr Adu itical c l a Nur t med- re sing surg hom e un it Ope T o rati t ng r al Mu Post a oom ltip nes le p the sia rac Ped tice ar iatr eas Ped i iatr c gene ic cr r itica al l ca re Reh Other abil itat ion Out Obstet r pat ient ics de Onc pt Pall olo gy iati ve/ hos pice

1.0

2012

2013

2014

20 0

New York Center for Health Workforce Studies (2008), p. 74.

65 11 3 8

2010

2011

Note: This table reflects OSHA’s enforcement data as of April 2015 and does not include any information on whether any of these citations are currently being contested.

Table 8 Nine States With Requirements Similar to OSHA’s Voluntary Guidelines of an Effective Workplace Violence Prevention Program (WVPP)

Components California

Connecticut

Illinoise Maine Maryland

New Jersey

New York

Oregon

Washington

Management commitment and worker participation

Worksite analysis

Hazard prevention and control

Training

Recordkeeping

Program evalutation

Note: An “X” in this table indicates that the state requirement addresses the component of the OSHA federal guideline. According to information provided by federal agency officials, they have not assessed how well OSHA’s approach to helping prevent workplace violence is working. Because OSHA has not assessed the results of its education and enforcement efforts, it is not in a position to know whether they have helped mitigate incidences of workplace violence (United States Government Accountability Office, GAO, 2016, p. 33). The NYSDOL regulation requires the employer, with the Authorized Employee Representative, to evaluate the effectiveness of the WVPP, at least annually and/or after serious incidents. The employer should attempt to describe within their WVPP the triggering event that will initiate a review: For example, repeat incidents within a short time frame, an injury requiring more than basic first aid. The review should focus on incident trends and the effectiveness of the control measures. The review should also assess whether the reporting and record keeping systems have been effective in collecting all relevant information. Thus, without the prompting of the Authorized Employee Representative, program evaluation and effectiveness data will not necessarily be collected or made available for review.

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 9 Workplace Violence Prevention Stategies Used by Healthcare Facilities in Texas

Prevention strategy*

No. of facilities

% of facilities

Staff training

620

64.5%

Restricted access

362

37.7%

Exit strategies

296

30.8%

Alarms and monitors (including panic buttons)

273

28.4%

Availability of restraints and policies for use

234

24.3%

Availability of escorts

221

23.3%

Present or rounding security personnel

210

21.9%

Emergency response team

206

21.4%

Personal protective equipment

180

18.7%

Reducing crowding

110

11.4%

Chaperones (visiting in pairs)

104

10.8%

Other

7.5%

Metal detectors

2.7%

Note: The top three most successful strategies identified by the study were training/education/awareness (37.9%), present or rounding security personnel (8.6%), and restricted access (6.4%). Additionally, in the Texas (2015) study, 395 responding facilities (41.1%) claimed they periodically evaluated the effectiveness or impact of their workplace violence program or policy. Those same facilities were asked to evaluate particular elements of their workplace prevention policy for their effectiveness. Facilities with in-house staffing committees were asked if those committees considered incidents of workplace violence in developing and evaluating nurse staffing plans. While the majority of home health agencies, free-standing emergency centers, and nursing facilities did not have nurse staffing committees, the majority of facilities that did have nurse staffing committees responded that they considered incidents of workplace violence in the development of staffing plans. Hospitals were most likely to respond that their facilities had nurse staffing committees, but 40.2% of those committees did not consider incidents of workplace violence in the development of staffing plans (see Table 10 and 11).

2014, state officials from eight of the nine states conducted from two to 75 inspections of healthcare employers related to workplace violence (pp. 33–34). One state did not conduct inspections of healthcare employers regarding workplace violence, and completed inspections resulted in zero to 74 reported citations (see Table 8). Although New York State law makes it a felony to assault a nurse on duty, the data on whether having stricter penalties in place leads to lower rates of violence against nurses is inconclusive. Limited data prevent a comparison of incidence rates before and after the law went into effect. BLS data on intentional injury caused by another person isn’t available prior to 2012, and the NYS law went into effect in 2010. Along with the stricter penalties for people who assault nurses, the NYSDOL workplace violence law’s reporting requirements for hospitals also prevent a direct analysis and comparison (Durnbaugh, 2020). Despite more legislative protections, a paucity of cases have been filed. A search of Westlaw® and Justia U.S. Law® from 2005 to 2020 for New York cases filed by nurses under the felony assault law revealed that only two cases had been filed (People v. Dennis 53 Misc.3d 255, 35 N.Y.S.3d 883, 2016 WL 3908155, 2016 N.Y. Slip Op. 26223, N.Y.Sup., July 18, 2016 (NO. 1087/2012); People v. Price (Steven) 2018 NY Slip Op 50937(U)). This is purportedly due to the belief of many law enforcement officers that most patients who assault a nurse do not have the requisite “mental capacity” 18

to engage in an “intentional” act (Barnes, 2009; Copeland & Henry, 2017; Fanelli, 2017), as well as the difficulty an RN plaintiff has in proving a “physical injury.” A physical injury must allege: (a) a description of the injury, its nature or location on the body; (b) the amount of force employed by the defendant; (c) that the pain experienced by the complaining witness persisted for any duration of time after the incident itself; and (d) the impact of the defendant’s alleged conduct on the complaining witness, such as

Your organization should provide adequate support to ensure that when a nurse is a victim of an assault, a police report is filed. The hospital should either file the charge on behalf of the injured RN or assist the RN to file charges by providing necessary information as part of the charges. Additionally, the employee should be

Journal of the New York State Nurses Association, Volume 48, Number 1

given time off from work to recover from their injuries and testify in the criminal case.

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 10 Elements of Workplace Violence Program That Texas Healthcare Facilities Evaluated

Type of cost

Hospital

FEC

Nursing facility

HHA

Number of violent incidents recorded

89.9%

Location or unit which incident occurred

87.0%

90.9%

79.8%

90.4%

27.3%

80.6%

75.9%

Injury severity result from incident

76.1%

45.5%

76.0%

73.5%

Time at which incident occurred

81.8%

36.4%

73.6%

69.9%

Nursing procedure being conducged at time of incident

47.8%

27.3%

72.9%

68.7%

Staffing level at time of incident

56.0%

45.5%

62.8%

36.1%

Perpetrator characteristics

37.1%

24.3%

53.2%

42.2%

Costs associated with incidents

57.9%

9.1%

37.2%

24.1%

Other

6.9%

9.1%

7.0%

4.8%

*Only 56% of less-than 395 responding facilities assessed staffing for evaluation purposes following a violent event.

Table 11 Did Texas’ Organization’s Staffing Committee Consider Workplace Violence in Nurse Staffing Plans?

Facility type

Yes

I don't know/ I am unsure

My organization does not have a nurse staffing committee

Hospital

38.5%

40.2%

15.9%

5.4%

FEC

22.2%

2.8%

72.2%

Nursing facility

18.3%

10.3%

10.9%

60.6%

HHA

15.9%

5.5%

8.3%

70.3%

Total

25.6%

20.3%

11.9%

42.2%

*Only 25.6% of all surveyed healthcare facilities’ staffing committees considered workplace violence in nurse staffing plans.

whether it affected her ability to perform certain tasks, from which the court could determine whether any purported injury, viewed objectively, meets the threshold level of “physical injury” (People v. A.S. 2010 NY Slip Op 20171 [28 Misc 3d 381]; Phillips, 2016). Relatedly, a review of the literature reveals a paucity of data evaluating healthcare employer violence prevention strategies. A search of the literature reveals over 135 studies that describe various strategies to reduce workplace violence, but of those studies, only about 40 identified specific interventions and failed to provide any empirical evidence on whether the strategies worked to reduce violence. Nine studies conducted in the healthcare setting also identified interventions, but all nine studies had inconclusive results and used flawed experimental designs (Heckermann et al., 2015; McPhaul & Lipscomb, 2004; Phillips, 2016; Runyan et al., 2000; Spelten et al., 2020). In one survey study conducted by the Texas Center for Nursing Workforce Studies (2016), 961 Texas healthcare facilities responded to a series of questions regarding the types of prevention strategies they incorporated into their violence mitigation policies. Table 9 shows the number and percentage of facilities that implemented various strategies to prevent or reduce workplace violence against nurses. The majority of the facilities offered staff training

(64.5%) as their primary strategy. The next most popular strategies were restricted access (37.7%) and exit strategies (30.8%). “Other” strategies included involving law enforcement (six facilities) and use of emergency codes (three facilities). Notably, none of the facilities used increased staffing as a strategy to reduce violence in the healthcare setting. In another study conducted by Arnetz et al., (2017), 41 units across seven hospitals were randomized into intervention (n = 21) and control (n = 20) groups. Intervention units received unit-level violence data to facilitate development of an action plan for violence prevention, while no data was presented to control units. The intervention used in the control group was designed to be unit-based and data driven, and was comprised of a worksite visit, or “walk-through.” Walk-throughs were conducted during daytime hours on a single occasion on each of the 21 intervention units over a 6-week period in 2013 from August 30 to October 16. The walkthrough was designed to take no more than 45 minutes so as to minimize disruption to clinical care. While the researchers did not see statistically significant decreases in event and injury rates in the intervention group at 6, 12, and 24 months post-intervention, they did find significantly lower risks (changes made in the environment to address potential opportunities) for both events and injuries in that group over time compared to controls.

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Finding Real Solutions The literature provides a handful of ways nurses can demand workplaces that mitigate violence risks for employees from their employers. A review of the literature supports the following initiatives (Alabama State Nurses Association, 2020; Cheny, 2019; McPhaul & Lipscomb, 2004; Morris, 2018; The Financial Impact of Workplace Violence, n.d.).

File Charges Based on New York State Felony D Law Your organization should provide adequate support to ensure that when a nurse is a victim of an assault, a police report is filed. The hospital should either file the charge on behalf of the injured RN or assist the RN to file charges by providing necessary information as part of the charges. Additionally, the employee should be given time off from work to recover from their injuries and testify in the criminal case. Emotional support should be provided through an employer paid employee assistance program (Appelbaum & Appelbaum, 1991). Appelbaum and Appelbaum (1991) wrote a paper regarding the prosecution of patients for violent behavior, a proposed hospital policy that included a statement of ethical principles for determining whether to prosecute patients, and a 16-step procedure for pursuing criminal charges that can be used as a guide.

Influence Organizational Safety Employers should provide you with a safe working environment and culture. Employers should develop, implement, and enforce a comprehensive safety infrastructure that does the following:  enhances hiring practices to screen out violence prone applicants;  develops emergency protocols with police;  enhances physical security;  establishes incident-reporting systems to capture all violent incidents;  creates interprofessional workplace violence steering committees;

 develops organizational policies and procedures related to safety and workplace violence, as well as human resources support;  provides workplace violence-prevention and safety education using evidence-based curriculum;  designs administrative, director, and manager guidelines and responsibilities regarding communication and staff support for victims of patient violence and those who witness it;  uses rapid response teams (including police, security, and protective services) to respond to violent behaviors;  delineates violence risk indicators to proactively identify patients with these behaviors;  creates scorecards to benchmark quality indicators and outcomes;  posts accessible resources on the organization’s intranet;  conducts periodic violence prevention assessments; and  promotes effective investigations and creates dedicated teams to probe workplace violence incidents.

Advocate for the Workplace You Deserve Through Collective Bargaining Physically violent patients create a workplace that’s not conducive to compassionate care and creates chaos and distractions. Nurses must advocate for a culture of safety by bargaining with their employer to establish violence-prevention policies, to increase staffing, and to provide support when an incident occurs. Contractual nurse staffing committees should consider incidents of workplace violence when developing and evaluating staffing plans. Research has shown that adequate staffing is a crucial factor in determining the quality and safety of the practice environment and that understaffing contributes to episodes of workplace violence (Gad & Elkazeh, 2013; Joint Commission, 2018; Lee et al., 1999; Whitman, 2017). Incidents of violence in all forms constitute important information for nurse staffing committee consideration. Additionally,

Figure 1 NIOSH Hierarchy of Controls Increased Effectiveness and Sustainability

Elimination

Remove the Hazard Before an Incident Can Occur

Substitution

Replace or Change the Hazardous Situation

Engineering Controls Higher Training, Monitoring and Supervision Needed

Administrative and Workplace Controls

Require a Physical Change to the Workplace Prevent Physical Access Isolate People From the Hazard Require the Employer or Employee to DO Something Change the System and How People Work—Increase Staffing Policies and Procedures, Mandatory Educations

Personal Protective Equipment

Journal of the New York State Nurses Association, Volume 48, Number 1

Requires the Employer to Provide, and Employee to Wear Protective Clothing

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

nurse staffing levels should be analyzed when violent incidents are evaluated (Department of State Health Services, 2016).

 a policy statement and assignment of oversight and prevention responsibilities;

Following a thorough search of the literature, and to the authors’ knowledge, increased nurse-to-patient ratios as an intervention for reducing workplace violence has not been rigorously tested in scientific studies. Moreover, this factor, while extremely important, does not shed light on the totality of the healthcare organization’s broader culture of safety or its role in protecting workers from potential violence-related harm. In healthcare settings, a culture of safety describes an organization’s overall commitment to safety, encompassing comprehensive and numerous efforts to protect both patients and workers from harm. Efforts that maximize the OSHA and NIOSH hierarchy of controls recommendations can be negotiated, emphasizing those controls that lead to a more effective level of control appropriate to the risk (see Figure 1).

 a workplace violence hazard assessment and security analysis, including a list of the risk factors identified and how the employer will address them;

Nurses’ unions can demand, through concerted activity, implementation of the OSHA managerial, administrative, and engineering controls throughout their facilities (Lied, 2013). Engineering controls include:

 development of workplace violence controls, including implementation of engineering and administrative controls and methods to prevent workplace violence incidents;  a record-keeping system designed to report any violent incidents;  a workplace violence hazard assessment and security analysis, including a list of the risk factors identified and how the employer will address them;  development of workplace violence controls, including implementation of engineering and administrative controls and methods to prevent workplace violence incidents;  a record-keeping system designed to report any violent incidents, including; 

 installing and regularly maintaining alarm systems and other security devices where risk is apparent or may be anticipated and arranging for a reliable response system when an alarm is triggered;  providing metal detectors—installed or hand-held, where appropriate— to detect guns, knives or other weapons;  using closed-circuit recording on a 24-hour basis in high-risk areas;  placing curved mirrors at hallway intersections or concealed areas;  locking all unused doors to limit access in accordance with local fire codes;  installing bright, effective lighting both indoors and outdoors and replacing burnt-out lights and broken windows and locks; and  keeping automobiles well maintained if they are used in the field (home care nurses), and locked at all times. Administrative controls to reduce exposure to hazards, include:  establishing liaisons with local police and state prosecutors, reporting all incidents of violence, and giving police physical layouts of facilities to expedite investigations;  requiring employees to report all assaults or threats to a supervisor and keeping log books and reports of such incidents to help determine necessary actions to prevent recurrences; and  a dvising employees of company procedures for requesting police assistance or filing charges when assaulted and helping them do so, if necessary. Managerial controls to support staff during emergencies and responding promptly to all complaints include:  setting up a trained response team to respond to emergencies;  using properly trained security officers to deal with aggressive behavior;  following written security procedures; and  increasing staffing levels. Furthermore, a written, comprehensive WVPP should be developed that includes:



consistent and continuous review of OSHA/PESH logs by nurse-led staffing, health and safety, and nursing practice committees; and c onsistent and continuous review of Protest of Assignment Forms by nurse-led staffing, health and safety, and nursing practice committees;

 development of a workplace violence training program that includes a written outline or lesson plan; and  annual review of the program, which should be updated as necessary. Such review and updates shall set forth any mitigating steps taken in response to any workplace violence incidents;  development of procedures and responsibilities to be taken in the event of a violent incident in the workplace; and  development of a response team responsible for immediate care of victims, re-establishment of work areas and processes, and debriefing sessions with victims and coworkers.

Implement Workplace Violence Prevention Initiatives Through Pilot Studies In a 2019 effort to prompt a comprehensive culture of safety at the workplace, the New York State Nurses Association (NYSNA) negotiated for newer and improved workplace violence protection initiatives at several hospitals. The new contractual language was formulated based upon a conceptual model of organizational determinants of workplace violence against hospital workers from Arnetz, Hamblin, Sudan, and Arnetz (2018) (see Figure 2).

Pilot Study Design and Data Collections In the fall of 2019, the New York State Nurse Association conducted an analysis of the 2019 OSHA logs of five-private-sector hospitals located in Brooklyn (2), Staten Island (1), Queens (1), and Bronx (1), New York, in order to gather information about the numbers of physical and verbal assaults perpetrated against nurses. A review of the logs revealed a total of 1,508 members listed as injured or ill throughout all units across the five hospitals, with 151 of those members having been assaulted. The

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

total number of reported member cases of workers who had to be away from work as a result of an injury due to an assault was 67 cases, with a collective total of 939 days. Fifteen member cases included workers who were away from work for more than 10 days as a result of a one-injury episode. Among the five facilities, 10% of documented injuries were due to assaults (see Table 12). To make a comparative judgment on whether the total number of reported cases of assaults against RNs documented on the 2019 OSHA logs (n = 9) at the Staten Island facility was a true indication of the actual numbers of assaults of RNs, NYSNA conducted a small convenience sample survey of RNs who were working in 2019 in the emergency department, behavioral health, and medical-surgical units. Those units were chosen in accordance with the findings of the New York Center for Health Workforce Studies (2008) that the highest risk of violence was perceived by RNs working in behavioral health, the emergency department, and medical-surgical units. Nurses from those units were

Figure 2 Organizational Determinants of Workplace Violence

recruited for the survey based upon a one-day visit to the hospital unit where nurses on duty that day were asked to fill out the survey on their break time. Permission to conduct the survey in the nurses’ lounge was obtained from the managers of the units visited. See Appendix A and B for copies of the survey and consent form. Results of the total numbers of surveys taken in the Staten Island Hospital (N = 22) (see Table 13) revealed that the OSHA log reported incidences (n = 9) did not capture the accurate numbers of assaults that occurred hospital-wide in 2019 (n = 17). The survey data revealed a total number of combined physical and verbal assaults (n = 17), with (n = 3) of the total 17 injuries due to physical assaults, and (n = 15) of the total 17 injuries due to verbal assaults. This data thus corroborates the literature findings that assaults in healthcare settings are underreported within the OSHA logs, and verbal incidences of violence are neither reported nor recorded (Copeland & Henry, 2017; Fagan & Hodgson, 2016; Fredrickson, 2020; Phillips, 2016; Wuellner & Bonauto, 2014).

Discussion This study reviewed the various measures that have been implemented in New York State over the past decade to mitigate and prevent workplace violence in healthcare settings to determine the following:

Work Stressors:

1. Do current federal and state laws, regulations, and guidance significantly reduce the incidences of workplace violence against nurses in New York healthcare settings?

Inadequate Numbers of Staff Patient Acuity High Caseload too High

2. Are there any other measures that can be taken by a union that significantly reduces the incidences of workplace violence against nurses in healthcare settings?

Not Enough Resources Too Many Admissions/Discharges

Staff Interactions: Interpersonal Conflicts

Research Question 1: Do Current Federal and State Laws, Regulations, and Guidance Significantly Reduce the Incidences of Workplace Violence Against Nurses in New York Healthcare Settings?

Communications Skills Teamwork Work Efficiency Measures

Replace or Change Culture of Safey Climate: Violence Prevention Policies Violence Task Force Facility Risk Assessments Enhances Physical Security Visitor Screenings Hazardous Situation

Workplace Violence

Violence protocols: Filing Felony D Report Security Rounding Maintaining/Reviewing OSHA/PESH Logs

Workplace violence is a significant problem in healthcare, and far too many nurses sustain verbal and physical assaults when performing their

Table 12 Comparison of Numbers of Assaults Against Nurses Compared to all Other Incidents 100% 14.9% 80%

3.4%

15.9%

4.4%

8.2%

60% 85.1% 40%

96.6%

84.1%

95.6%

91.8%

20% Note: Workplace violence encompasses both verbal and physical violence. NYSNA’s new language includes increased staffing in nursing specialty units, formation of labormanagement workplace violence committees, and consistent and regular conduct of workplace violence risk assessments and incident investigations. Annual review of OSHA and PESH logs is also part of the risk assessment plan.

Adapted from Arnetz, Hamblin, Sudan, & Arnetz (2018), conceptual model, p. 14. 22

Journal of the New York State Nurses Association, Volume 48, Number 1

Hospital A: Hospital B: Hospital C: Hospital D: Hospital E: Brooklyn Staten Island Brooklyn Queens Bronx RN reported assults cases RN reported incidence

41 276

263 245 45

735

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Table 13 NYSNA 2019 Convenience Sampling Workplace Violence Survey: Hospital B (Staten Island) Units Total # surveys (n = 22)

I have been assaulted physically

I have been assaulted verbally

By a patient

By a visitor

Emergency department (ED) (n = 9)

ED (n = 3)

No assaults

Medical-surgical (MS) (n = 2) MS (n = 3) Psych (n = 4) Psych (n = 1) TOTALS

Units Total # surveys (n = 22)

2 No assaults 5

I have been assaulted 2–5 times

I have been assaulted 6–10 times

I have been assaulted 11 or more times

No assaults 2

No assaults

By staff

No assaults 2 No assaults 12

Took time Change made Assault not What What steps away Assault Assault reported Injury as a on unit as could have should be from work a result of prevented the taken reported to reported to result following because of security supervisor reason not assault assault? assault? reported assault

ED (n = 9)

Management response time

1 6

More security rounding

Patient was special needs

De-escalating communication

More support from management Remove person from premises Security intervention

ED (n = 3) MS (n = 2)

Having supervisor take action

Nothing was done

MS (n = 3) Psych (n = 4) 2

Anti-anxiety medications for patient

Security presence on each unit

Faster response time from security Better policies

Psych (n = 1) TOTALS

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

In health care, nurses provide a majority of the services and time spent in caring for patients, but all too frequently, they end up in a conflicted situation. They have to decide if they are going to protect themselves or their patients in violent situations, and some nurses who become victims of violence and fight back actually get accused by their employers of doing something wrong.

clinical assignments. Violence against healthcare workers has increased so much in recent years that it can now be classified as an epidemic of violence. The numbers speak for themselves. The 2018 U.S. Bureau of Labor Statistics recently found that incidents of serious workplace violence are five times more common in healthcare than in the private industry (BLS, 2018a), and the U.S. Department of Justice indicates that 500,000 or more nurses each year become victims of violent crimes in the workplace. Indeed, 32 states in the United States, including New York State, have responded to the increasing statistics of violence against nurses by making physical assaults against nurses a felony. These felony laws carry a oneto-seven-year imprisonment consequence for assaulting a nurse. Nevertheless, holding perpetrators of workplace violence and abuse accountable for their crimes against nurses and other healthcare workers remains a significant burden of the injured worker themselves. Frequently, management does not support the filing of a felony charge, nor do they provide assistance in the criminal process and procedure (Copeland & Henry, 2017; Fagan & Hodgson, 2016; Fredrickson, 2020; Phillips, 2016; Wuellner & Bonauto, 2014). The convenience survey NYSNA conducted corroborates this finding within the literature. Of the 22 respondents to the survey, all respondents indicated they had been assaulted a minimum of two times in 2019 (for a minimum of 44 assaults perpetrated on three different specialty hospital units: emergency department, behavioral health, and medical-surgical units), and all but one respondent reported the assault to their supervisor and/or security officer, yet the OSHA logs documented only nine incidences of assault against a nurse throughout the entire hospital. Similarly, a search of Westlaw® and Justia U.S. Law® from 2005 to 2020 for New York cases filed by nurses under the felony assault law revealed that only two cases had been filed by the District Attorneys in New York State. One can reasonably conclude, therefore, that the criminal justice system and local law enforcement agencies are not helpful to nurses who want to pursue assault charges. Indeed, the literature indicates that prosecutors often seek a lesser charge, such as harassment or disorderly conduct charge, to secure a conviction by plea, avoiding the risks of losing the case on more serious charges at trial. This outcome has been reported as the most likely result following an actual assault against a nurse (Starr, 2019). Thus, the NYS Felony D law is, overall, not an effective means to mitigate workplace violence. This conclusion is also supported by the 24

literature review of the paucity of cases that have been filed throughout the United States, purportedly due to the belief of many law enforcement officers and district attorneys that most patients who assault a nurse do not have the requisite “mental capacity” to engage in an “intentional” act (Barnes, 2009; Copeland & Henry, 2017; Fanelli, 2017) and the difficulty RN plaintiffs have in proving their own physical injury. A similar conclusion can reasonably be made of the federal antiworkplace violence regulation under OSHA. Only a small percentage of the OSHA inspections resulted in general duty clause citations related to workplace violence, and this is corroborated in the literature. The GAO (2016) reported that over a 24-year period from 1991 through April 2015, OSHA issued only 18 general duty clause citations to healthcare employers across the United States for failing to address workplace violence. At no time has OSHA fully assessed the results of its efforts to address workplace violence in healthcare facilities. Without assessing these results, OSHA is not in a position to know whether its efforts to have healthcare facilities voluntarily engage in initiatives to reduce violence against nurses in accordance with its guidelines are effective, or if additional action may be needed to address this hazard (GAO, 2016). Furthermore, an analogous conclusion can be reasonably made about the (non) effectiveness of NYSDOL’s WVPP regulations. The NYSDOL antiworkplace violence regulation requires the employer, with the Authorized Employee Representative, to evaluate the effectiveness of the WVPP, at least annually and/or after serious incidents. The employer should attempt to describe within their WVPP the triggering event that will initiate a review. For example, repeat incidents within a short time frame, or an injury requiring more than basic first aid. The review should focus on incident trends and the effectiveness of the control measures. The review should also assess whether the reporting and record-keeping systems have been effective in collecting all relevant information. Thus, without the affirmativeaction prompting of the Authorized Employee Representative, program evaluation and effectiveness data will not necessarily be collected or made available for review. Moreover, the 2016 GAO report indicates that out of nine states with comparable state regulations to the federal OSHA voluntary recommendations, and from 2010 through 2014, state officials from eight of the nine states (New York is included in the eight states) conducted only two to 75 inspections of healthcare employers related to workplace violence (pp. 33–34). One state did not conduct inspections of healthcare employers regarding workplace violence, and completed inspections resulted only in between zero to 74 reported citations.

Research Question 2: Are There Any Other Measures That Can Be Taken by a Union That Significantly Reduce the Incidences of Workplace Violence Against Nurses in the Healthcare Setting? Healthcare workers continually become the subjects of patients’ and family members’ rage, confusion, and/or anxiety. Studies show over and over again that violence against healthcare workers, and particularly nurses, has become a rising epidemic. One can reason that a major facilitating factor is that hospitals admit too many patients and there are not sufficient resources (particularly adequate numbers of qualified staff) to care for them or ensure safety for everyone in the facility. In health care, nurses provide a majority of the services and time spent in caring for patients, but all too frequently, they end up in a conflicted situation. They have to decide if they are going to protect themselves or their

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

patients in violent situations, and some nurses who become victims of violence and fight back actually get accused by their employers of doing something wrong. While it seems apparent that initiatives thus far have neither been effective nor efficient in deterring violence against nurses in the healthcare setting, Turner (2018) does offer some solutions a union can negotiate with the employer to bolster the effectiveness of current violence prevention initiatives, including, but not limited to:  flagging potentially violent patients before admission and taking proactive actions, such as transferring the patient to a forensic facility and/or ordering a 1:1 provider-to-patient ratio for that patient;  increasing all staffing levels on all units to prevent patients from becoming frustrated over long waits;  conducting regular and consistent facility assessments and increasing all staffing levels to correlate with the true numbers and incidences of violence on all units;  creating a culture of safety wherein any assault against any healthcare worker must be processed by the hospital as a felony;  ensuring an alliance with law enforcement officials and providing no less than the presence two law enforcement officers with every charge against an offender;

Violence against nurses is not “part of the job.”

Conclusion Workplace violence in health care can be compared to domestic violence a generation ago when police, prosecutors, judges, and society at large were too often dismissive of the problem. Domestic violence victims were sent the wrong message: “This is just a private matter; under the law, it’s not possible for your spouse to assault you.” And the remedies that were utilized were equally as trivializing. To the perpetrator, police advised: “Just take a walk around the block and cool down” and to the victim: “Stop doing whatever you were doing to precipitate the event and fuel the anger.” Eventually, law enforcement, the courts, and victims began working together to change those perceptions and reactions. Society now tells victims of domestic violence that it is never okay for a spouse or significant other to use violence against a person, regardless of their relationship, and that no provocation makes violence either warranted or acceptable (Keating, 2007).

The same paradigm shift in perceptions, responses, and standards should be applied to the victims of workplace violence in healthcare  providing locator badges with panic buttons for victims to signal settings. It is never okay for one person to use violence against another, for help; no matter what the situation is. Violence against nurses is not “part  respecting and encouraging the exercise of whistleblower and anti- of the job.” We nurses have all experienced today’s fast-paced and, at retaliation protections so healthcare workers are assured of the same times, highly emotional healthcare environments as both employees basic rights as any other assault victim—the right to report to law and as family members. Patients are in pain, waits are long, and family members and friends can become extremely distressed primarily due enforcement and to press charges;  pursuing legislative action by lobbying for nurse-to-patient ratio laws; to feelings of loss of control. Nevertheless, violence in the workplace has a negative effect on everyone: victims, patients, family members,  ensuring that facility staffing committees comprised of direct care witnesses, the workforce, and the healthcare organization itself. In nurses can review OSHA and PESH logs and incident reports, and give addition to physical injuries, victims and witnesses suffer psychological the committees significant influence on facility-wide staffing plans; trauma, the entire staff feels less safe, and the healthcare organization  providing measures that make the physical environment safer, such as may be faced with low employee morale, monetary losses, and liability bullet and shatter-proof barriers, better lighting in parking areas and and embarrassing public relations issues. All parties should be invested patient care areas, metal detectors to detect and remove weapons, in effectuating real change. alarm systems, closed-circuit videos, limited access and locked In a concerted effort to determine if union staffing committees, health areas (staff rooms, medication rooms, and treatment rooms), and an and safety committees, and labor management committees comprised arrangement of furniture that prevents staff entrapment; of bedside nurses (all of whom have the power to influence facility providing education on de-escalation techniques to defuse danger; and  limiting the numbers of visitors and permissible hours of visitation. Ultimately, because WVPPs that are tailored to a healthcare organization’s specific needs will be most effective in reducing the frequency and severity of violent incidents, collective bargaining becomes an indispensable and essential component to mitigate the rate of violence against nurses in healthcare settings.

wide staffing plans, facility risk assessments, and workplace violence action plans and policies) will mitigate instances of workplace violence, NYSNA has recently negotiated with the five aforementioned New York hospitals for improvements in the implementation and enforcement of newer staffing ratios and WVPPs. Research will be conducted in the spring of 2021 to determine if these negotiated benefits and efforts have made a statistically significant impact in reducing violence against our most precious and valuable human resource in our healthcare facilities: our nurses.

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

n References AFL-CIO. (2019). Protect Workers From Violence on the Job. https://aflcio. org/sites/default/files/2019-05/HR%201309%20WPV%20factsheet.pdf Alabama State Nurses Association. (2020). https://alabamanurses. org/2019/06/patient-violence-its-not-all-in-a-days-work/ American Nurses Association. (2019). Workplace violence. https://www. nursingworld.org/practice-policy/advocacy/state/workplace-violence2/ Appelbaum, K. L., & Appelbaum, P. S. (1991). A model hospital policy on prosecuting patients for presumptively criminal acts. Hosp Community Psychiatry. 42(12), 1233–1237. https://doi.org/10.1176/ps.42.12.1233 Arnetz, J. E., Hamblin, L. E., Russell, J., Upfal, M. J., Luborsky, M., Janisse, J., & Essenmacher, L. (2017). Preventing patient-to-worker violence in hospitals: Outcome of a randomized controlled intervention. Journal of Occupational and Environmental Medicine, 59(1), 18–27. https:// doi.org/10.1097/JOM.0000000000000909 Arnetz, J., Hamblin, L. E., Sudan, S., & Arnetz, B. (2018). Organizational determinants of workplace violence against hospital workers. Journal of Occupational and Environmental Medicine, 60(8), 693–699. https://doi.org/10.1097/JOM.0000000000001345 Barnes, B. (2009). A question of assault. American Psychiatric Nurses Association. https://community.apna.org/blogs/barbarabarnes/2009/12/09/a-question-of-assault Burdick, G. (2019, December). House passes healthcare workplace violence bill. EHS Daily Advisor. https://ehsdailyadvisor.blr.com/2019/12/housepasses-healthcare-workplace-violence-bill/ Center for Health Workforce Studies: School of Public Health. (2008, May). The hospital nursing workforce in New York: Findings from a survey of hospital registered nurses. SUNY University at Albany. https://www.albany.edu/news/pdf_files/0805_Hospital_Workforce_ Survey.pdf Cheny, C. (2019, March 27). 6 steps to manage violence against hospital healthcare workers. HealthLeaders. https://www.healthleadersmedia. com/clinical-care/6-steps-manage-violence-against-hospitalhealthcare-workers Copeland, D., & Henry, M. (2017, March-April). Workplace violence and perceptions of safety among emergency department staff members: Experiences, expectations, tolerance, reporting, and recommendations. Journal of Trauma Nursing, 24(2), 65–77. https:// nursing.ceconnection.com/ovidfiles/00043860-201703000-00003.pdf Department of Health Services. (2016). Workplace violence against nurses in Texas. A report required by Texas Health and Safety Code Section 105.009. https://cdn.ymaws.com/www.texasnurse.org/resource/ resmgr/docs/doc_workplace_violence__repo.pdf Duncan, S., Estabrooks, C. A., & Reimer, M. (2000). Violence against nurses. AltaRN, 56(2), 13–14. Durnbaugh, E. (2020, January 10). Patients who abuse Michigan nurses rarely face charges. Healthcare workers seek tougher laws. Times Herald. https://www.thetimesherald.com/story/news/local/2020/01/09/ michigan-nurses-workplace-violence-laws-assault/2847645001/ 26

Fagan, K. M., & Hodgson, M. J. (2016). Under-recording of work-related injuries and illnesses: An OSHA priority. Journal of Safety Research. https://www.osha.gov/ooc/underrecording_fagan_hodgson.pdf Fanelli, J. (2017, June 14). NYC psych ward worker who was attacked by patient says she can’t bear idea of returning to job as violent residents go unpunished. New York Daily News. https://www.nydailynews. com/new-york/brooklyn/attack-patient-leaves-nyc-psych-wardworker-questioning-job-article-1.3245492 Faragher v. City of Boca Raton, 524 U.S. 775 (1998). Oyez. http://www. oyez.org/cases/1997/97-282 Fredrickson, C. (2020). 7 reasons employees don’t report workplace violence. Business Know-How. https://www.businessknowhow.com/ manage/reportviolence.htm Gad, R. A. E. A., & Elkazeh, E. A. E. E. (2013). The effect of workplace violence on nurses’ job satisfaction. Zagazig Nursing Journal, 9(2), 162 –178. https://www.researchgate.net/publication/322909901_ The_Effect_of_Workplace_Violence_on_Nurses’_Job_Satisfaction Harun, N., Martiniano, R., Rodat, C., & Moore J. (October 2016). A profile of registered nurses in New York State. Center for Health Workforce Studies, School of Public Health, SUNY Albany. http://www.chwsny. org/wp-content/uploads/2016/10/RN-Profile-NY-2016_-1.pdf Healthy Work Strategies. (2019). Legislation and regulation to prevent workplace violence in Healthcare. https://healthywork.org/ wp-content/uploads/2019/09/019-HWC-Website-Page-ContentResources-Healthy-Work-Strategies-Legislation-reg-preventworkplace-violence-healthcare-v1-092019-300res-CYMK.pdf Heckermann, B., Zeller, A., Hahn, S., Dassen, T., Schols, J. M., & Halfens, R. J. (2015). The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting: A narrative review of current literature. Nurse Educ. Today, 35(1), 212–219. https://doi.org/10.1016/j.nedt.2014.08.003 Hoel, H., Sparks, K., & Cooper, C. L. (n.d.). The Cost of Violence/Stress at work and the Benefits of a Violence/Stress-Free Working Environment. University of Manchester Institute of Science and Technology. https:// www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/--safework/documents/publication/wcms_108532.pdf Itzhaki, M., Bluvstein, I., Peles-Bortz, A., Kostistky, H., Bar Noy, D., Filshtinsky, V., & Theilla, M. (2018). Mental health nurse’s exposure to workplace violence leads to job stress, which leads to reduced professional quality of life. Frontiers in Psychiatry, 9. https://doi. org/10.3389/fpsyt.2018.00059 Joint Commission. (2018, April 17). Sentinel Event Alert: Physical and verbal violence against health care workers. 59. https://www. jointcommission.org/-/media/documents/office-quality-and-patientsafety/sea_59_workplace_violence_4_13_18_final.pdf?db=web&ha sh=9E659237DBAF28F07982817322B99FFB Keating, W. R. (2007). Protecting our caregivers from workplace violence. The Commonwealth of Massachusetts: Norfolk District Attorney’s Office. http://faculty.uml.edu/jbyrne/44.327/ProtectingOurCaregivers.pdf

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Lebron, A. (2020, April). The latest on workplace violence statistics. https://www.ravemobilesafety.com/blog/latest-workplace-violencestatistics Lebron, A. (2019, January). Most state laws to prevent workplace violence in healthcare fail to protect traveling nurses. Rave Mobile Safety. https://www.ravemobilesafety.com/blog/most-state-laws-to-preventworkplace-violence-in-healthcare-fail-to-protect-traveling-nurses Lee, S. S., Gerberich, S. C., Waller, L. A., Anderson, A., & McGovern, P. (1999). Work-related assault injuries among nurses. Epidemiology, 10(6), 685–691. Lied, M. R. (2013). OSHA recommendations to reduce risk of workplace violence. Peoria. https://www.peoriamagazines.com/ibi/2013/mar/ osha-recommendations-reduce-risk-workplace-violence McPhaul, K. M., & Lipscomb, J. A. (2004). Workplace violence in health care: Recognized but not regulated. OJIN, 9(3), Manuscript 6. http:// ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/ ViolenceinHealthCare.aspx Morris, N. (2018, November 18). Should health-care workers press charges against violent patients? The Washington Post. https://www. washingtonpost.com/national/health-science/should-health-careworkers-press-charges-against-violent-patients/2018/11/16/668ad5c0d7b6-11e8-a10f-b51546b10756_story.html National Institute for Occupational Safety and Health. (2014). Violence occupational hazards in hospitals. https://www.cdc.gov/niosh/ docs/2002-101/default.html New York State Department of Labor. (n.d.). Workplace violence prevention for New York State public employers. https://labor.ny.gov/ workerprotection/safetyhealth/workplaceviolence.shtm Occupational Safety and Health Administration. (2013, September). Facts about hospital worker safety. https://www.osha.gov/dsg/hospitals/ documents/1.2_Factbook_508.pdf. People v. A.S., Slip Op 20171 [28 Misc 3d 381] (New York 2010) Phillips, J. P. (2016). Workplace violence against health care workers in the United States N Eng J Med, 374(17), 1661–1669. https://doi. org/10.1056/NEJMra1501998 Runyan, C. W., Zakocs, R. C., & Zwerling, C. (2000). Administrative and behavioral interventions for workplace violence prevention. Am J Prev Med, 18(4Suppl), 116–127. https://doi.org/10.1016/s07493797(00)00147-1

Spelten, E., Thomas, B., O’Meara, P. F., Maguire, B. J., FitzGerald, D., & Begg S. J. (2020, April 29) Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database. https://doi. org/10.1002/14651858.CD012662.pub2 Starr, K. T. (2019). After a physical assault by a patient: What are your options? Nursing2019, 49(6), 12–13. https://www.nursingcenter. com/journalarticle?Article_ID=5004246&Journal_ID=54016&Issue_ ID=5004241 Texas Center for Nursing Workforce Studies. (2016). Workplace violence against nurses survey. Publication #:25-14922. https://cdn.ymaws. com/www.texasnurses.org/resource/resmgr/docs/WPVAN_ Report_12142016.pdf The Financial Impact of Workplace Violence. (n.d.). http://www. workplaceviolence911.com/docs/FinancialImpactofWV.pdf Turner, J. (2018, October 29). Nurse legal rights in the workplace. Minority Nurse. https://minoritynurse.com/nurse-legal-rights-in-the-workplace/ United States Government Accountability Office. (2016). Workplace safety and health: Additional efforts needed to help protect health care workers from workplace violence. https://www.gao.gov/ assets/680/675858.pdf U.S. Bureau of Labor Statistics. (2018a). Occupational injuries and illnesses among registered nurses. https://www.bls.gov/opub/mlr/2018/article/ occupational-injuries-and-illnesses-among-registered-nurses.htm U.S. Bureau of Labor Statistics. (2018b). Workplace Violence in Healthcare, 2018 [Fact sheet]. https://www.bls.gov/iif/oshwc/cfoi/workplaceviolence-healthcare-2018.htm Whitman, E. (2017, March 15). Health care violence is a growing problem— but people disagree about how to solve it. Advisory Board. https:// www.advisory.com/daily-briefing/2017/03/15/health-care-stakeholders World Health Organization. (2002). Framework guidelines for addressing workplace violence in the health sector. https://www. who.int/violence_injury_prevention/violence/interpersonal/en/ WVguidelinesEN.pdf?ua=1&ua=1 Wuellner, S. E., & Bonauto, D. K. (2014). Exploring the relationship between employer recordkeeping and underreporting in the BLS survey of occupational injuries and illnesses. American Journal of Industrial Medicine, 57, 1133–1143. https://onlinelibrary.wiley.com/ doi/pdf/10.1002/ajim.22350

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Appendix A NYSNA Workplace Violence Survey

Workplace Violence Survey Facility Name: Unit:  Have you ever been assaulted (pushed, kicked, slapped, spat on, etc.) or verbally threatened with physical harm on the job? ____Yes ____No  If yes by whom? ____Visitor ____Staff ____Patient ____Other  When did this occur?  At your current facility, on which unit did the assault(s) occur?  To whom did you report the assault? (check all that apply) ____Hospital police ____Supervisor ____Other  Were you injured as a result of the assault? ____Yes ____No  If yes, did you have to take time away from work as a result of your injury.  How many days were you off of work as a result of injury?  Were there any changes made as a result of your assault? ____Yes ____No  If yes, please explain.  Were there any factors, that you think could have prevented or contributed to this event occurring? ____Yes ____No  If yes, please explain.  What steps would you like to see taken to prevent the type of incident that happened to you from happening again?

Journal of the New York State Nurses Association, Volume 48, Number 1

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence

Appendix B

Recruitment Script and Consent Process

THE CITY UNIVERSITY OF NEW YORK New York State Nurses Association Department of Occupational Health and Safety Recruitment Script TITLE OF RESEARCH STUDY: Violence in the Workplace PRINCIPLE INVESTIGATOR: Onica Britton, MSN, RN, NP-BC Student in Health Policy and Management Hello: My name is Onica Britton and I am a graduate student at CUNY School of Public Health. I am administering a brief survey on workplace violence to get a better understanding of the rate and extent of workplace violence occurrence. The survey shouldn’t take more than 5 minutes of your time, and all your responses will be anonymous. Is this something you might be interested in?” [if yes, proceed] “Great”. [read oral consent, ask participant if they have questions, if no questions, procced]. “Here is a copy of the survey, please fill it out and submit it at the drop box located in the main conference room.” Thank you for your participation,

Onica Britton CUNY School of Public Health MPH Student

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3 Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, MSN, RN-BC, NPD Christina DeGaray, MPH, RN-BC

n Abstract The COVID-19 pandemic in spring of 2020 presented nurses throughout the United States, and in particular in New York State, with the experience of extreme stress due to the sheer numbers of hospitalized patients, shortages in human and material resources, and uncertain clinical protocols in treating the virus. Lack of adequate personal protection equipment (PPE), gaps in competency related to limited knowledge about the virus and its treatment, being floated to areas outside of nurses’ clinical expertise, nurse-to-patient ratios that were worsened due to the masses of patients affected by the virus, and strained hospital capacities further exacerbated nurses’ stress, burnout, and depression levels over and above previously reported levels in the literature. Nevertheless, nurses’ unions continue to make important contributions toward helping nurses reduce stress, burnout, depression, and compassion fatigue—even as the SARS COVID-19 virus escalates these conditions for New York nurses. Unions help nurses prepare for the next COVID surge, epidemic, pandemic, or disaster, and mitigate lapses in institutional practices during a pandemic. Keywords: COVID patients, pandemics, nurses, stress, team nursing, nursing care, competency, stress reduction

Introduction Nurses’ associations and unions are situated to improve nurses’ stress from the hospital level to unit and individual member level. This report is the third part in a series describing a current effort by nursing unions to help reduce stress, burnout, depression, and compassion fatigue among nurses represented by the New York State Nurses Association (NYSNA) in acute care hospitals (Contreras et al., 2020). Job stress is defined as, “the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker” (Sauter et al., 1999, p. 6). Working conditions and worker characteristics contribute to workplace stress

(Sauter et al., 1999). Prolonged exposure to stress may lead to depression, compassion fatigue, and burnout. The SARS-CoV-2 virus created a worldwide pandemic not seen since the H1N1 influenza A virus pandemic of 1918, when 500 million people were infected between February 1918 and April 1920. In its first nine months, the current pandemic infected 32,475,260 worldwide and was growing by more than 300,000 cases per day (WorldOMeter, 2020). As of September 24, 2020, COVID-19 cases in the United States had reached 6,916,292, with a total of 302,715 of those cases reported just within the previous seven days. The total number of deaths in the United States at the time stood at 201,411 people (CDC COVID data tracker, 2020).

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, MSN, RN-BC, NPD, and Christina DeGaray, MPH, RN-BC Nursing Education and Practice, New York State Nurses Association 30

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

during the pandemic were rooted in feelings of fear, lack of control, extreme stress and anxiety, nervousness, and a lack of educational orientation to the patient population and environment (Lafontant et al., 2019).

Many nurses were required to leave their areas of specialty care to work in newly created COVID care settings. To meet the

Study Aims

needs of the massive numbers of COVID

The purpose of this study was to:

patients, hospital managers mandated

1. evaluate the reasons the COVID-19 pandemic fostered and further exacerbated the anxiety, burnout, depression, and compassion fatigue of New York Nurses; and

operating room nurses, post-anesthesia care unit nurses, psychiatric-mental health nurses, endoscopy nurses, and nurses from

2. evaluate those interventions provided by nurses’ unions that effectively reduced the feelings of anxiety and inadequacy in nurses during a pandemic.

other areas of specialty to float to and work in either a medical-surgical setting or critical care setting for COVID-19 patients.

Conceptual Underpinnings

When the virus first reached New York City on February 29, 2020, a record 12,274 new cases were reported by April 4. By April 10, New York State had more confirmed cases than any other country outside of the United States. As of September 23, 2020, New York had reported 10 million tests, with 451,892 positive cases, and 25,437 deaths (New York State COVID-19 Tracker). As a result of the pandemic, New York State had to increase its hospital bed capacity from 53,000 to 90,000 beds. This was accomplished by converting other specialty care units to COVID units and constructing temporary facilities. Through these efforts, New York was able to increase its number of beds from 2.7 beds per 1,000 New Yorkers in 2018 to 4.6 per 1,000 New Yorkers. Of note, New Yorkers had only 2.7 hospital beds per 1,000 New Yorkers in 2018 due to hospital closures resulting from the 2005 Berger Commission’s recommended closure of nine hospitals and the downsizing, reassignment of services, or mergers that impacted an additional 48 hospitals (Robinson, 2020). During the peak of the virus in New York in April 2020, hospitals were prohibited from performing elective surgeries and procedures. COVID19 cases were high, particularly in the New York City metropolitan area. Consequently, many nurses were required to leave their areas of specialty care to work in newly created COVID care settings. To meet the needs of the massive numbers of COVID patients, hospital managers mandated operating room nurses, post-anesthesia care unit nurses, psychiatric-mental health nurses, endoscopy nurses, and nurses from other areas of specialty to float to and work in either a medical-surgical setting or critical care setting for COVID-19 patients. Nurse staffing has been identified as one of the most important variables to influence patient outcomes, including mortality, nosocomial infections, and patient satisfaction. While floating of nurses is a common practice most healthcare institutions use to cover staffing shortages in other patient care areas, it is a driver of low nursing morale and satisfaction, disengagement, perceived lack of organizational support, and increased turnover (Bitanga, 2020). In addition, research has indicated that floating is described by nurses as a difficult, stressful, and challenging as it engenders the questioning of one’s competence and fear of making a mistake, harming one’s patients, and potentially losing one’s license. Psychological components of floating

Maslow’s hierarchy of needs comprises the theoretical basis and conceptual underpinnings of this study. Maslow’s theory informs us that humans have a series of needs, some of which are rudimentary and must be met before a person can turn their attention toward other needs. Maslow further informs us that meeting one’s basic needs will have a significant place in providing a foundation for people to be able have the desire and motivation to fulfill higher needs, such as fulfilling one’s life’s purpose. Worries over safety and physiological needs are the major reasons for mental disorders, such as anxiety, phobia, depression, and post-traumatic stress syndrome (PTSD) (Zheng, et.al, 2016) (see Figure 1).

Figure 1 Maslow’s Hierarchy of Need

Self-fulliment needs

Self actualization: achieving one’s full potential, including creative activities

Esteem needs: prestige and feeling of accomplishment

Psychological needs



Belongingness and love needs: intimate relationships, friends Safety needs: security, safety

Basic needs



Physiological needs: food, water, warmth, rest

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Methods Participants and Survey Design During the height of the COVID-19 pandemic in 2020, NYSNA conducted two surveys and sent them to registered professional nurses throughout the state. The NYSNA COVID-19 Member Survey was a 27-question tool sent in March 2020 to more than 44,000 NYSNA members, and that survey elicited information on nurses’ working conditions and employer preparedness (see Appendix A). The NYSNA COVID-19 Member Survey educed over 2,000 responses. The NYSNA COVID-19 Patient Care

Survey was a 48-question tool that was sent in May 2020 to a random sample of 422 nurses. The survey elicited information on nurses’ stress levels while working during the pandemic (see Appendix B). The NYSNA COVID-19 Patient Care Survey educed 62 responses.

Results and Discussion Only two coronaviruses have previously caused pandemics. The first of these was the SARS (severe acute respiratory syndrome) coronavirus,

Figure 3 NYSNA COVID-19 Patient Care Survey Q22

When nurses are overwhelmed,

Q22 Which of the working conditions below would you rate as the most stressful?

their mental health can be severely compromised.

Answered 60 Skipped 2

Not stressful

Treating patients with ... The possiblity of patients ... The lack of PPE Working in a speciality ... Contracting COVID Working with medications ...

Minimally stressful

Working with venitlators Working with nurses who ...

Figure 2 NYSNA COVID-19 Patient Care Survey Q12 Q12 How Stressful was it treating patients with diagnosis where so little is known, including treatment options? Answered 58 Skipped 4

Too many of my ... To many patient deaths

Moderately stressful

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Very stressful

Answer Choices

Extremely stressful 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Not stressful

Responses

Treating patients with a diagnosis where so little is known, including treatment options

13.33%

The possibility of patients deteriorating suddenly

21.67%

The lack of PPE

10.00%

Working in a speciality area I am not used to

11.67%

Contracting COVID-19

20.00%

0.00%

Working with medications I am not familiar with

5.00%

Minimally stressful

3.45%

Working with ventilators

0.00%

Moderately stressful

8.62%

Working with nurses who are not interested in team nursing

1.67%

Very stressful

36.21%

Too many of my coworkers getting sick

3.33%

Extremely stressful

51.72%

Too many patient deaths

13.33%

Total

Total 32

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

SARS-CoV, which started in China in 2002. The second was the MERS (Middle East respiratory syndrome) coronavirus, MERS-CoV, which emerged in Saudi Arabia in 2012. Researchers from Chinese institutions have used state-of-the-art genome sequencing tools to identify the DNA structure of the novel coronavirus, SARS-CoV-2. Researchers have found that 88% of the COVID-19 virus’s genomic sequence is the same as two bat coronaviruses to which SARS-CoV-2 is believed to be most similar: bat-SL-CoVZC45 and bat-SL-CoVZXC21. Their study further shows that the SARS-CoV-2 DNA is about 79% the same as SARS-CoV and approximately 50% the same as that of MERS-CoV (Medical News Today, 2020).

news about coronavirus and its trends, transmissions, best practices for treatments, immune responses, long-term effects, and impact on our day-to-day lives has been unrelenting and alarming. One nurse surveyed described it as, “like rolling the dice to see what worked for your patients… [and wondering] am I hurting my patient or actually trying to help?” Indeed, during New York’s April 2020 peak, most nurses surveyed (87%) reported “very stressed” to “extreme levels of stress” because of all of the unknowns (see Figure 2).

A vast source of anxiety for nurses over the COVID-19 virus is the fact that there are currently no targeted, specialized treatments for mild or moderate cases. When doctors detect a SARS-CoV-2 infection, they generally aim to treat the symptoms as they arise. The changing

When nurses are overwhelmed, their mental health can be severely compromised. Previous research has corroborated that the level of burnout, depression, and anxiety during the COVID-19 pandemic is high (Hu et al., 2020). Our own survey validates this finding. Many reasons were indicated for high stress levels in the working environment. The top five reasons for very stressful and extremely stressful working conditions reported by surveyed nurses were: (a) the possibility of patients deteriorating suddenly;

Figure 4 NYSNA COVID-19 Patient Care Survey Q13

Figure 5 NYSNA COVID-19 Patient Care Survey Q16

Q13 How stressful was it working with the possibility the patient will suddenly deteriorate?

Q16 How stressful was it working with the possibility of contracting COVID-19?

Answered 59 Skipped 3

Answered 60 Skipped 2

Not stressful

Minimally stressful

Moderately stressful

Very stressful

Extremely stressful

Extremely stressful 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Not stressful

0.00%

Not stressful

0.00%

Minimally stressful

1.69%

Minimally stressful

3.33%

Moderately stressful

13.56%

Moderately stressful

6.67%

Very stressful

27.12%

Very stressful

21.67%

Extremely stressful

57.63%

Extremely stressful

68.33%

Total

85% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the speed with which patients deteriorated.

90% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the fear of contracting the virus.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

(b) contracting the COVID virus themselves; (c) treating patients where so little is known, including treatment options; (d) watching too many patients die; and (e) being floated and working in a specialty care area they were not used to (see Figure 3).

Top Five Stress Triggers for Nurses Research has indicated that when nurses are exposed to a prolonged and sustained period of watching patients die and to deteriorating clinical situations with no end in sight, they will sink into a state of burnout and depression (Ku et al., 2020). Our study indicates that due to the life-threatening nature of COVID-19, the uncertainties of the situation, the uncertainties of clinical competence (due to being floated to clinical areas of practice unfamiliar to the practitioner), and the increasing workload, more than 80% of surveyed nurses felt very stressed to extremely stressed (see Figures 2, 4–7).

Figure 6 NYSNA COVID-19 Patient Care Survey Q21

Other Stress Triggers for Nurses Many other disturbing consequences of the pandemic contribute to nurses’ stress and safety concerns. Nurses who came in close contact with COVID patients while providing necessary care often experienced inadequate protections from contamination, high risks of nosocomial infection, emotional exhaustion, burnout, fear, anxiety, and depression. The COVID-19 outbreak led to a sharp increase in admissions and presentations to hospitals, and consequently impacted the workload of nurses. Studies have indicated that each additional patient added to a nurse’s workload is associated with a 23% increase in the likelihood of burnout and stress (Aiken et al., 2002; Hu et al., 2020). As the numbers of infection and mortality cases surged, nurses watched their coworkers develop COVID as a result of inadequate PPE and a lack of environmental safeguards, such as ventilation systems and HEPA filter air purification systems. Watching coworkers get sick resulted in “very stressed” to “extreme levels of stress” in 82% of surveyed nurses (see Figure 8). Nurses constitute the largest part of the healthcare workforce in an epidemic and they undertake most of the tasks related to infectious disease containment. Although it is a necessary infection control resource, extended wear of PPE, such as an N95 face mask, for greater than 4 hours, particularly for those with pre-existing headaches, may contribute to or exacerbate headache (Ong et al., 2020). Additionally, irritation to skin is experienced by many nurses using the N95, especially along the nasal bridge (Shaukat et al., 2020), and studies indicate that nurses’ burnout, anxiety, and depression

Q21 How stressful was it having too many patient deaths? Answered 58 Skipped 4

Not stressful

Figure 7 NYSNA COVID-19 Patient Care Survey Q4

Minimally stressful

Q4 While treating COVID-19 patients, are you working on the same unit where you normally work?

Moderately stressful

Answered 62 Skipped 0

Very stressful

Yes

Extremely stressful

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Responses

Not stressful

0.00%

Minimally stressful

0.00%

Moderately stressful

12.07%

Yes

46.77%

Very stressful

32.76%

53.23%

Extremely stressful

55.17%

Total

88% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the numbers of patient deaths. 34

Answer Choices

Responses

53% of surveyed nurses were floated to a clinical specialty practice are that they were not hired for and/or used to.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

were positively correlated with skin lesion, which means that the worse the skin lesion, the higher the burnout, anxiety, and depression levels reported (Hu et al., 2020). Nevertheless, 93% of surveyed nurses expressed “very stressed” to “extreme levels of stress” over the lack of available PPE altogether (see Figure 9).

Nurses who came in close contact with COVID patients while providing necessary care often experienced inadequate

Indeed, a majority of nurses surveyed had little confidence in their employer’s pandemic preparedness and ability to keep the environment, staff, and patients safe (see Figures 10–12).

protections from contamination, high risks of nosocomial infection, emotional exhaustion, burnout, fear, anxiety, and depression.

Figure 7 (continued) NYSNA COVID-19 Patient Care Survey Q15 Q15 How stressful was it working in a speciality are you are not used to? Answered 60 Skipped 2

The New York response to COVID-19 made it clear that hospitals were not adequately prepared to handle the pandemic. Researchers have shown that hospitals will only have enough beds to meet demand in a best-case scenario of a patient population infection rate of 20% over a year. This assumes half of the hospital beds are repurposed to specifically treat COVID-19 patients. In a worst-case scenario, in which 60% of the population falls sick and the virus spreads over six months, seven times more hospital beds would be needed than are currently available. Aside

Figure 8 NYSNA COVID-19 Patient Care Survey Q20 Q20 How stressful was it having too many of your coworkers get sick?

Not stressful

Answered 60 Skipped 2

Minimally stressful

Not stressful

Moderately stressful

Minimally stressful

Very stressful

Moderately stressful

Extremely stressful Not applicable did not work outside my specialty area

Very stressful

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Not applicable

Not stressful

1.67%

Minimally stressful

3.33%

Moderately stressful

8.33%

Very stressful

15.00%

Extremely stressful

43.33%

Not applicable did not work outside my specialty area

28.33%

Total

Extremely stressful

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Not stressful

0.00%

Minimally stressful

1.67%

Moderately stressful

11.67%

Very stressful

21.67%

Extremely stressful

60.00%

Not applicable coworkers did not get sick

5.00%

While 28% of nurses surveyed remained on their home units, 58% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because they were working on specialty care units they were not used to.

Total

Journal of the New York State Nurses Association, Volume 48, Number 1

60 35

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

from beds, our hospitals suffer equipment shortages—including masks, PPE, and ventilators—that threaten the health and safety of patients and providers (Shah & Kocher, 2020). To mitigate equipment shortages, federal regulatory agencies and New York regulatory agencies and hospitals downgraded usual and customary infection control measures by ordering its nurses to reuse infection control equipment (see Figure 13). This mandate met with significant concern and disagreement by the NYSNA and healthcare workers throughout the state.

But given the frequency and disruption caused by large-scale epidemics and pandemics, that should change. (Shah & Kocher, 2020) The profit-driven incentives that counter hospital pandemic preparedness are corroborated by our survey responses. Hospitals throughout New York State had only one to two airborne isolation infection rooms available, according to 69% of the 1,679 nurses surveyed (see Figure 14).

Hospitals, which have continued to consolidate and prioritize efficiency over the past decades, have little incentive to build additional, expensive, negative-pressure rooms for single patients. They do not want to order extra ventilators for ICU beds, which are costly and may not serve patients outside of a pandemic. They seek to avoid the economic damages and public stigma of converting to facilities for large-scale triage or quarantine. Furthermore, as more care is shifted to the home, hospice, and outpatient settings, the number of existing ICU beds nationwide have been declining.

In particular, the staffing of nurses (under normal circumstances nurses are staffed at minimum levels), failed to meet the vast numbers of patients needing care during the pandemic. Consequently, hospitals were unprepared to meet the nursing needs of COVID patients. Staffing shortages impeded a number of essential patient care activities, such as pronation for patients on ventilators. Early in the pandemic, the act of turning patients onto a prone position was determined to be effective at improving patient oxygenation (Jiang et al., 2020). However, it requires sufficient staff to move the body weight, while managing connected biometric monitors, IV lines, and oxygen delivery devices (see Figure 15 and 16).

Figure 9 NYSNA COVID-19 Patient Care Survey Q14

Figure 10 NYSNA COVID-19 Member Survey Q21

Q14 How stressful was it working with a lack of PPE?

Q21 Are you confident your employer has sufficent PPE on hand to protect staff if there is a rapid surge in patients with possible COVID-19?

Answered 59 Skipped 3

Answered 1,992 Skipped 14

Not stressful

Minimally stressful

Yes

Moderately stressful

Very stressful I don’t know

Extremely stressful

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Not stressful

1.69%

Yes

6.53%

130

Minimally stressful

1.69%

59.74%

1,190

Moderately stressful

5.08%

I don’t know

33.73%

672

Very stressful

27.12%

Extremely stressful

64.41%

Total 36

38 59

Total

1,992

60% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the lack of confidence the employer had sufficient PPE.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

In addition to burnout, depression, stress, and extreme fatigue, nurses confront moral distress in a pandemic (Bevin, 2020). Inadequate numbers of available resources such as oxygen and ventilators for patients in need were a major source of moral distress for nurses. During the height of the COVID pandemic, New York hospitals were preparing to use a ventilator on more than one patient, thus reducing the time any one patient would have access to that ventilator. This scarcity would have created moral distress for nurses forced to withdraw life support from one person for the benefit of another. Such decisions are so emotionally and ethically fraught that the phrase “fair allocation” in relation to ventilators seems inappropriate. To emphasize this moral dilemma and distress, one surveyed nurse said, “One day the ED ran out of oxygen. You start watching your patients become confused. I can’t help them. His face starts to change color and

Figure 11 NYSNA COVID-19 Member Survey Q7

he starts foaming at the mouth, and, I’m like, my patient is dying in front of my eyes for air and I can’t give it to him.” Another remarked, “I remember a patient who clearly needed to be intubated. However, we only had one ventilator left, so we spoke to the family…who decided they wouldn’t want him intubated anyway…. So, yes…a shortage of equipment...caused moral distress.” The Society of Critical Care Medicine (2020) published a joint consensus statement that strongly advised against the sharing of ventilators. Additionally, when a hospital must make the tragic decision to withhold treatment due to insufficient supplies, the use of a committee guided by policy would remove the weight of these choices from any one individual, spreading the burden among all members of the committee, whose broader responsibility is to save the most lives.

Figure 12 NYSNA COVID-19 Member Survey Q13

Q7 How would you rate your employers’ implementation of plans for protecting the Coronavirus/COVID-19 epidemic?

Q13 Do you have access to the following personal protective equipment (PPE) for airborne precautions on your unit? Please select each PPE item you currently have access to.

Answered 1,995 Skipped 11

Answered 1,971 Skipped 35

Yes

Gloves Good

Impermeable gowns

Poor

Face shields/goggles

Very poor

N95 respirators

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

PAPR respirators

Responses

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Excellent

5.41%

108

Good

32.58%

650

Poor

42.81%

854

Gloves

99.19%

1,955

Very poor

19.20%

383

Impermeable gowns

70.22%

1,384

1,995

Face shields/goggles

67.68%

1,334

N95 respirators

54.64%

1,077

PAPR respirators

5.78%

114

Total

62% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the lack of the employers implementation plans for protecting employees during the pandemic.

Answer Choices

Total

Responses

1,971

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Fortunately for New Yorkers, Governor Andrew Cuomo was able to coordinate resources and shift a sufficient supply of ventilators among New York State hospitals. Even so, moderate-to-extreme stress was experienced by many nurses with little-to-no experience in the care of vented patients when nurses were floated from their areas of clinical specialty to COVID-19 patient care (see Figure 17).

Union Interventions to Mitigate Nurses’ Stress During a Pandemic Enhanced Communication Protocols Communications with family members were strained at the peak of the pandemic due to policies that prohibited visitors for COVID-19 patients. This placed an additional emotional burden on nurses and other healthcare providers. Unions encouraged employers to adopt updated communication protocols, such as the use of iPads for patients. One nurse surveyed indicated, “We did the best we could with the situation we had. Nurses offered their cell phones so a patient could say goodbye to the families, or be with them.” The use of iPads served a dual purpose: It decreased the number of times nurses and other healthcare workers need to expose themselves to an infected patient, and it increased communications between and among patients, staff, and family members (see Figure 18).

Safer Use of Infusion Pumps to Decrease Nurses’ Stress Some New York employers required that their nurses implement the use of extended IV tubing on IV pumps in order to place IV poles either

Figure 12 (continued) NYSNA COVID-19 Member Survey Q15

closer to the door or outside of the patient’s room. This practice was one way in which hospitals attempted to reduce nurses’ exposure to infected patients. Although the extended IV tubing did reduce the numbers of times nurses needed to come into close contact with the COVID-19 patient, this mandated practice nevertheless added to nurses’ anxiety levels because it: (a) diminished the ability to assess the patient’s IV site; (b) disturbed infection control because it required the patient door to remain open thereby increasing the possibility of infecting other staff and patients; and (c) disturbed the ability to access the entire IV tubing for unwanted air bubbles. The NYSNA was able to end this practice via collective action based upon its survey results (see Figure 19).

Team Nursing to Decrease Stress, Improve Patient Care, and Facilitate Nurse Competency Team nursing is a model that pairs nurses experienced in the patient population and patient acuities with less experienced nurses. Establishing proficient teams requires the charge nurse to have a good understanding of each nurse’s skills set, education, qualifications, and competence. Team nursing is the gold standard during pandemics, particularly when the majority of a facility’s nurses will be floated to patient units they are unfamiliar with. Team nursing has been found to be a vital support to

Figure 13 NYSNA COVID-19 Member Survey Q16 Q16 Are staff currently required, or will be required, to reuse N95 respirators while caring for COVID-19 patients? Answered 1,900 Skipped 100

Q15 Is the correct size based on your fit test available for your use on the unit?

Yes

Answered 1,945 Skipped 61

Yes

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Yes

53.06%

1,032

46.94%

913

Total

1,945

47% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because they did not have access to the correct “fit-tested” N95 respirator mask size. 38

Answer Choices

Responses

Yes

55.63%

1,057

44.37%

843

Total

1,900

54% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the lack of access to N95 respirators. 56% of surveyed nurses expressed feeling “very stressed” to “extreme levels of stress” because of the lack of access to sufficient quantities of N95 respirators and the employer’s requirement that nurses reuse their N95 respirators.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

inexperienced nurses (Press Ganey, 2020). Notably, this nursing model was created in the 1950s to address staffing shortages and to address a wide range of skill and competence.

“One day the ED ran out of oxygen. You start watching your patients become

During the height of the COVID-19 crisis, there was a significant influx of nurses coming from out of state, coming out of retirement and reinstating their licenses, and coming from Upstate hospitals to Downstate hospitals to work in New York City where the staffing needs were greatest. These nurses were assigned to work with COVID-19-infected patients in either a medical-surgical setting or an intensive care setting.

confused. I can’t help them. His face starts to change color and he starts foaming at the mouth, and, I’m like, my patient is dying in front of my eyes for air and I can’t give it to him.”

Figure 14 NYSNA COVID-19 Member Survey Q12 Q12 How many airborne infection isolation rooms are available? Answered 1,679 Skipped 327

The extreme stress experienced by all nurses, including nurse educators, was described as unprecedented. The pace required for nursing care on COVID units was unparalleled, and time was extremely limited for orientation and preceptor purposes. Varying and unknown levels of “visiting” practitioner skill, knowledge, and experience added to the chaos and stress in COVID units. Nurse Educators were inundated with consultations about how to treat COVID-19 patients at a time when treatment algorithms were simply not available. Because of these conditions, team nursing was recommended by the union and was found to increase morale and job satisfaction for nurses whose managers agreed to implement the team nursing model of care. Studies in the literature have shown that team nursing decreases the stress levels of both experienced and novice nurses, increases team work, increases confidence of less experienced nurses (the see one, do one, and teach one paradigm), and improves the quality and safety of patient care

1 2 3 4 5

Figure 15 NYSNA COVID-19 Member Survey Q18

6 7

Q18 Does your employer have a plan to address additional staff needed due to dedicated staff (1:1) for COVID-19 patients?

8 9

Answered 1,906 Skipped 100

10 11 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Yes

Responses

35.74%

600

33.29%

559

8.04%

135

7.27%

122

3.04%

2.50%

0.71%

1.49%

Yes

14.43%

275

0.54%

85.57%

1,631

1.31%

More than 10

6.08%

102

Total

1,679

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Total

Responses

1,906

86% of surveyed nurses expressed the employer was not prepared with additional staff needed to meet the clinical needs of the COVID-19 patient.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

(Fairbrother et al., 2010). Our surveys corroborate these research findings (see Figures 20–22).

Nurses’ Unions Can Reduce Anxiety Resulting from Lack of Knowledge, Skills, and Orientation

Methods

programs offered. Programs were scheduled at various times throughout the day and multiple times throughout the week in order to accommodate nurses’ working schedules. Each 4-hour program was given live over a 2-day period, for two hours each day via Zoom®. Nurses self-registered for the programs and provided evaluation data at the conclusion of the 2-day program.

Survey Design

Purpose of the Educational Program Although some facilities may have provided basic competency training to nurses who were mandated to float to medical-surgical and ICUs during the pandemic, many did not, because they simply did not have the time or resources to do so. To fill this much-needed gap for knowledge and support, the NYSNA, which represents over 44,000 nurses throughout New York State for collective bargaining purposes, developed two, 4-hour trainings for its nurses to bolster their confidence levels and to improve the competency of those RNs caring for patients being treated for COVID-19. Education on job-specific topics is known to reduce stress among nurses (Vnenchak et al., 2019; Xu et al., 2019).

Participants and Educational Program Design Nurses had very limited time to engage in educational programs during this crisis because they frequently were required to work extra hours. Nevertheless, over 500 nurses participated in the medical-surgical and ICU

Figure 15 (continued) NYSNA COVID-19 Member Survey Q17 Q17 If COVID-19 patients are cared for in your facility, is there a policy for dedicated staff caring only for these patients? Answered 1,894 Skipped 112

To further determine the efficaciousness of the educational programs provided, a 9-question NYSNA NEP COVID-19 Education Zoom Session Participant Survey was sent in April 2020 to the 500 nurses who participated in the online courses. The survey yielded a total of 79 responses. A copy of this survey is attached as Appendix C.

Results and Discussion Evaluation of these programs demonstrated that nurses had a substantial educational need to increase their clinical knowledge in order to adeptly care for the COVID-19 patient population. Of the nurses attending the 4-hour medical-surgical and ICU orientation programs, 94% of those surveyed indicated that the programs had a positive effect on their knowledge, 68% indicated that the programs had a positive effect on their skills, 71% indicated that the programs had a positive effect on their attitude, and 78% indicated that the programs had a positive effect on their practice (see Figure 23).

Figure 16 NYSNA COVID-19 Member Survey Q20 Q20 Does your employer have a plan to cover staff who many have quarantined during the epidemic? Answered 1,916 Skipped 70

Yes

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Responses

Answer Choices

Responses

Yes

21.28%

403

Yes

15.34%

294

78.72%

1,491

84.66%

1,622

1,894

Total

79% of surveyed nurses expressed the employer was not prepared with dedicated staff needed to meet the clinical needs of the COVID-19 patient. 40

1,916

85% of surveyed nurses expressed the employer was not prepared with additional staff needed to cover those employees who needed to be quarantined.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

At the height of the pandemic in New York, 90% of the nurses who took the educational programs found that the program enhanced their confidence working with COVID patients and 91% felt that the knowledge gained from these programs enhanced their clinical practice for COVID-19 and resulted in increased benefits for their COVID patients (see Figure 24). Sentiments about increased feelings of confidence and competency were expressed multiple times. Comments documented in the program evaluation forms included: “I have been out of the clinical setting for many years, so this workshop was very helpful”; “I had a decrease in anxiety due to unfamiliarity now that I have taken this program”; “I am better able to advocate for patients”; “As a pediatric NP working in the peds ED that was redeployed to the COVID ICU as an RN, this was a HUGE help and gave me some confidence to enter the unit”; “This program gave me more confidence along with feeling less stress”; “I stand up and speak up about the right PPEs”; “My vent care has improved”; and “My IV drip knowledge has improved.”

Figure 17 NYSNA COVID-19 Member Survey Q18

Lessons Learned: Preparing for the Next Wave of the Pandemic What should healthcare facilities and the government do to prepare for the next surge of COVID-19, particularly when it may coincide with the winter 2020–21 flu season? How will facilities be able to ensure sufficient supplies of PPE during a surge of the flu and COVID-19 simultaneously? How can hospitals safely cohort patients on units?

Figure 18 NYSNA COVID-19 Patient Care Survey Q24 Q24 Did your facility provide patients with an iPad or other device which enabled staff to communicate with patients from outside of their patient’s room? Check all that apply. Answered 54 Skipped 0

Q18 How stressful was it working with ventilators?

Yes, and I found this was very effective

Answered 60 Skipped 2

Not stressful

Yes, but I found it was not... to communicate

Minimally stressful

Yes, but I found it was not... to assess patient

Moderately stressful Very stressful

No, my employer did not provide...

Extremely stressful

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Not applicable

Answer Choices 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Not stressful

3.33%

Minimally stressful

5.00%

Moderately stressful

23.33%

Very stressful

11.67%

Extremely stressful

15.00%

Not applicable

41.67%

Total

Of those 58% of surveyed nurses who worked with ventilators, 86% of surveyed nurses expressed feelings of moderate to extreme stress working with ventilators.

Responses

Yes, and I found this very effective in communicating with and assessing the patient while decreasing the number of times I needed to enter the room.

18.52%

Yes, but I found it was not an effective way to communicate with the patient as their needs were so complex I needed to enter into the room anyway.

16.67%

Yes, but I found it was not an effective way to assess the patient.

0.00%

No, my employer did not provide devices to communicate with and assess patients from outside the room.

64.81%

Total

Of those nurses surveyed nurses, 65% did not have access to iPad, however, only 19% of surveyed nurses found the device to be an effective way to communicate with the patient without having to enter the room to assess the patient.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Our experiences can inform us, if we take heed. It is critical for healthcare facilities to learn from what happened in the spring of 2020 in order to guide us in best practices for what we may be facing in the near future. Undeniably, we should prepare for the next COVID-19 surge by instituting enhanced PPE standards and environmental controls. Enhanced PPE standards include:  s ufficient supplies of N95 respirators must be available for every patient caregiver and every practitioner in accordance with usual and customary, pre-COVID standards of practice;

Figure 19 NYSNA COVID-19 Patient Care Survey Q9 Q9 When treating COVID-19 patients, did you keep IV pumps outside of the patient rooms? Check all that apply. Answered 53 Skipped 9

 rationing and reusing of PPE designed for single use should be prevented;  fit testing for PPE should be ongoing as the need arises;  gowns, face shields, coveralls, head coverings, booties, gloves, and any other necessary PPE should be readily accessible without having to leave the unit;  only those PPE designed and/or manufactured to be decontaminated and reused should be redistributed;  stockpiles of a minimum of 90-day supplies of PPE should be maintained to protect against supply chain disruptions; and  hospitals should develop long-term purchasing and procurement plans to incorporate the use of reusable respiratory protection such as elastomeric respirators and powered air purifying respirators (PAPRs), which will reduce supply chain pressures and enhance resiliency for future surges. Creating robust environmental controls include the following:  All COVID-19 positive patients should be cohorted on separate units with enhanced PPE standards and dedicated staff to care for these patients.

Yes, and it was safer...

 Administrative controls should be established to ensure efficient cohorting of walk-in patients.

Yes, I felt it was...

 Facilities should conduct continuous assessments of donning and doffing skills.

Yes, it saved PPE by...

 Improvements should be made in any deficient decontamination areas.

Yes, it was easier...

Figure 20 NYSNA COVID-19 Patient Care Survey Q5

No, it was not safe for...

Q5 Is the unit you are working on while treating COVID-19 patients utilizing team nursing, or are nurses being paired together to address competency?

No, it was not safe for...

Answered 61 Skipped 1

No, because it diminishes... 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Yes

Responses

Yes, and it was safer for the patients

11.32%

Yes, I felt that it decreased my exposure to the virus

24.53%

Yes, it saved PPE by reducing the frequency of donning and doffing

26.42%

Yes, it was easier to hear the alarms

16.98%

No, it was not safe for the patient because you needed to use extension tubing

41.51%

No, it was not safe for the staff because it broke infection control

39.62%

No, because it diminshes the ability to access the patient's IV site

49.06%

Yes

45.90%

54.10%

Total

Of those nurses surveyed nurses, only 29% indicated that the benefits of placing IV pumps outside patient rooms outweighed the risks; however, 49% of surveyed nurses found the risks outweighed the benefits of this practice. 42

No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Total 46% of those nurses surveyed indicated that they implemented a team nursing model on their unit.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

 Pilot projects converting new areas into donning/doffing spaces on COVID-19 units and in procedural areas should be conducted, with plans implemented to ensure minimal viral contagion.

 knowing that everything is not within your control during a pandemic, so be kind to yourself;

 Facilities should provide enhanced ventilation systems.

 talking with people you trust and express your feelings over things that you cannot control;

 recognizing what you can accomplish given your circumstances;

Positive Coping Skills to Mitigate Stress

 periodically asking yourself, “How am I doing?”;

Anxiety, depression, insomnia, and distress was disproportionately found among female healthcare workers and nurses in one study (Shaukat et al., 2020). Nevertheless, in the midst of those negative emotions, many nurses benefited from positive coping skills such as building strong ties to team, family and friends, and self-care activities. As a result, those same nurses often experienced growth psychologically and professionally (Sun et al., 2020).

 noticing how you are feeling and responding to the stressors that you are experiencing;

Self-Care Actions Many nurses experienced a variety of mental health challenges during the pandemic, especially burnout and fear, which warrants more attention and support from communities such as colleagues, family, friends, employers, and policy makers. Some self-care activities and collective actions include:  sharing your worries with those you work with as well as family and friends;  developing individualized plans of action for self-care and to address the issues that are most worrisome to you;

 t aking stock of the effects of sleep deprivation, such as waking up frequently during the night, inability to sleep, waking up exhausted,

Figure 21 NYSNA COVID-19 Patient Care Survey Q6 Q6 Do you find that team nursing or nurse pairing supports safer nursing practice? Check all that apply. Answered 59 Skipped 3

Yes, for the nurses Not for the nurses Yes, for the patients

Figure 20 (continued) NYSNA COVID-19 Patient Care Survey Q7

Not for the patients

Q7 Do you find that team nursing or nurse pairing supports decreasing exposure to the coronavirus?

You and your coworkers...

Answered 59 Skipped 3

Management suggested and...

Yes

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices No 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Yes

57.63%

42.37%

Total

58% of those nurses surveyed indicated that team nursing was supportive in decreasing exposure of RNs to the COVID-19 virus.

Responses

Yes, for the nurses

81.36%

Not for the nurses

3.39%

Yes, for the patients

72.88%

Not for the patients

1.69%

You and your coworkers suggested it and implemented it

25.42%

Management suggested it and implemented it

23.73%

Total

14 59

81% of those nurses surveyed indicated that team nursing supported safer nursing practice for the nurses. 72% of those nurses surveyed indicated that team nursing supported safer nursing practice for the patients. 25% of those nurses surveyed indicated they suggested to the manager that the team nursing model be implemented on their units.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

having nightmares, and inability to focus, as well as feeling moderate or excessive fatigue, irritability, or marked anxiety;  every day and every shift that you at work, taking time to breathe, full slow breaths, ensuring that you are inhaling and exhaling equally with each breath. All of these self-help actions have been shown to decrease stress (Perciavalle et al., 2017).

Maintain Good Health Habits During times of stress, it is not uncommon to let go of self-care and engage in things that are less healthy, such as consuming alcohol, eating fast foods, or eating more or less than your body needs (Coons et al., 2020). Our resilience and immune systems are directly impacted by how we take care of ourselves. Getting eight hours of solid sleep, taking breaks

Figure 22 NYSNA COVID-19 Patient Care Survey Q8

Many nurses benefited from positive

Q8 Do you find that team nursing or nurse pairing decreased stress of the nurses involved? Check all that apply.

ties to team, family and friends, and

coping skills such as building strong self-care activities. As a result, those same nurses often experienced growth psychologically

Answered 57 Skipped 5

and professionally.

Yes, for the less...

Figure 23 NYSNA NEP COVID-19 Education Zoom Session Participant Survey Q5

Not for the less... Yes, for the more...

Q5 Has the program had a positive effect on... Check all that apply.

Not for the more...

Answered 77 Skipped 2

Yes for both working...

Knowledge

Yes, because it decreased... 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

Responses

Yes, for the less experienced nurse.

59.65%

Not for the less experienced nurse.

7.02%

Yes, for the more experienced nurse.

33.33%

Not for the more experienced nurse.

10.53%

Yes for both, working as a team nurses made me feel more supported.

75.44%

Yes, because it decreased the number of times I needed to enter the room.

28.07%

Total

Attitude

Practice 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices

75% of nurses surveyed indicated that team nursing reduced the stress level of both experienced and inexperienced nurses during the COVID-19 pandemic. More inexperienced nurses (60%) than experienced nurses. (33%) indicated they benefited by the team nursing model. Team nursing was also viewed as a benefit by 28% of those nurses surveyed due to the reduction in the numbers of times the nurse had to enter the COVID patient’s room. 44

Skills

Responses

Knowledge

93.51%

Skills

67.53%

Attitude

71.43%

Practice

77.92%

Total

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

at work, promoting teamwork, eating healthy food in the quantities that our body needs, prioritizing aerobic exercise, doing things we love to do, laughing, dancing, singing, connecting with nature, and expressing our feelings with people we trust all go a long way toward staying physically and emotionally healthy.

Take Collective Action in Support of One Another and in Support of Our Communities Collective action refers to actions taken by a group of people whose goal is to achieve a common objective. Collective action can make the difference between isolation, depression, and PTSD, or connection, resilience, and having a generally positive experience. During a crisis, acting

Figure 24 NYSNA NEP COVID-19 Education Zoom Session Participant Survey Q7 Q7 Looking back, do you think that the program has enhanced... Answered 79 Skipped 0

...your confidence...

collectively rather than individually can be more effective in addressing concerns, decreasing the burden on any one individual, and having a broader positive impact on one’s community. Collective action does the very thing that is needed during a crisis: It can bring people together in support of one another. Nurses and the nursing profession have the power, if they choose to take it, to engage in conversation and collective advocacy and action to help move healthcare in a direction that is for the good of all in society (Osingada & Porta, 2020). During the initial wave of the COVID-19 pandemic, it became abundantly clear that health care in the United States was filled with inequities, disparities, and injustice. People of color were more likely to die of COVID-19 regardless of socioeconomic, behavioral, or metabolic factors (Raisi-Estabragh et al., 2020; Okoh et al., 2020). Collective advocacy in the form of peaceful rallies, political action in the form of contacting legislators to change healthcare policies and procedures, and antiracist patient advocacy within healthcare settings to promote equitable, individualized patient care can help to mitigate health injustices.

Conclusion Despite the impact the COVID-19 pandemic has had on nurses’ time both professionally (related to overtime and intensity of work) and personally (related to increased demands such as child care needs, home schooling, and caring for elderly parents and family members), nurses continue their commitment to provide safe, competent care for COVID-infected patients. Similarly, although the prevalence of burnout, anxiety, depression, fear, and moral distress is high during a pandemic, nurses continue to express their willingness to participate in frontline work. Willingness and intention to voluntary and actively care for patients during any pandemic is an important factor in mitigating nurse burnout, anxiety, depression, and fear. Ideas from nurses should be continuously solicited and addressed to facilitate nurses’ willingness to care for COVID19 patients. The role of unions to represent frontline nurses zealously and amplify nurses’ suggestions on how to improve their working conditions, welfare, and living conditions is more critical now than ever.

...your working as a...

...your clinical practice of...

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Yes

Answer Choices

Yes

Total Weighted Average

Your confidence working with COVID patients?

89.74% 70

10.26% 8

1.10

Your working as a multidisciplinary team member?

88.31% 68

11.69% 9

1.12

Your clinical practice of the COVID patient to the benefit of the patient?

90.79% 69

9.21% 7

1.09

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

n References Aiken, L. H., Clarke, S. P., Sloane, D. M., et al. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987–1993 Bevin, A. (2020). Positive mental health during the COVID-19 pandemic: anxiety or moral distress? Journal of Kidney Care, 5(3), 116–119. https://doi.org/10.12968/jokc.2020.5.3.116 Bitanga, M. E. (2020). What are the effects of floating to nurses and patient care? RN Journal of Nursing. https://rn-journal.com/journalof-nursing/effects-of-floating-to-nurses-and-patient-care Centers for Disease Control and Prevention. (2020). CDC COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#cases_ casesinlast7days City of New York (2020). NYC Health COVID 19 data. https://www1.nyc. gov/site/doh/covid/covid-19-data.page Contreras Sollazzo, L., Esposito, C. (2020). Nurses’ unions can help reduce stress, burnout, depression, and compassion fatigue part 1: The background. Journal of the New York State Nurses Association, 47(1), 18–44. Coons, H. L., Berkowitz, S., & Davis, R. (2020, March 26). Self-care advices for health-care providers during COVID-19: Concrete strategies to help manage stress. American Psychological Association Services. https://www.apaservices.org/practice/ce/self-care/healthproviders-covid-19?_ga=2.132714062.1525404165.15917290331593448908.1591729033 Hu, D., Kongb, Y., Lic, W., Hand, Q., Zhange, X., Zhuf, L. X., Wanf, S. W., Liuc, Z., Shenc, Q., Yangc, J., Hef, H. G., Zhu, J. (2020). Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study. EClinicalMedicine, 24, 1–10. https://www. thelancet.com/action/showPdf?pii=S2589-5370%2820%2930168-1 Jiang, L. G., LeBaron, J., Bodnar, D., Caputo, N. D., Chang, B. P., Chiricolo, G., Flores, S., Kenny, J., Melville, L., Sayan, O., Sharma, M., Shemesh, A., Suh, E., Brenna, F. (2020). Conscious proning: An introduction of a proning protocol for nonintubated, awake, hypoxic emergency department COVID-19 patients. Academic Emergency Medicine, 27(7), 566–569. https://doi.org/10.1111/acem.14035 Lafontant, M. M., Blevins, D. Romer, C., & Ward, P. G. (2019). Exploring nurses’ feelings on floating: A phenomenological study. Nursing & Health Sciences Research Journal, 2(1), 21–29. https://scholarlycommons.baptisthealth.net/cgi/viewcontent. cgi?article=1025&context=nhsrj Medical News Today. (2020). Novel coronavirus: Your questions, answered. https://www.medicalnewstoday.com/articles/novelcoronavirus-your-questions-answered New York State (2020). New York Forward. Daily hospitalization summary by region. https://forward.ny.gov/daily-hospitalizationsummary-region

Okoh, A. K., Sossou, C., Dangayach, N. S., Meledathu, S., Phillips, O., Raczek, C., Patti, M., Kang, N., Hirji, S., Cathcart, C., Engell, C., Cohen, M., Nagarakanti, S., Bishburg, E., Grewal, H. (2020). Coronavirus disease 19 in minority populations of Newark, New Jersey. International Journal for Equity in Health, 19(1), 1–8. https:// doi.org/10.1186/s12939-020-01208-1 Osingada, C. P., & Porta, C. M. (2020). Nursing and sustainable development goals (SDGs) in a COVID-19 world: The state of the science and a call for nursing to lead. Public Health Nursing, 37(5), 799–805. https://doi.org/10.1111/phn.12776 Perciavalle, V., Blandini, M., Fecarotta, P., Buscemi, A., Corrado, D., Bertolo, L., Di Corrado, D., Fichera, F., Coco, M. (2017). The role of deep breathing on stress. Neurological Sciences, 38(3), 451–458. https:// doi.org/10.1007/s10072-016-2790-8 Press Ganey (2020). Rapid task education for frontline staff: Using high reliability tools. http://healthcare.pressganey.com/2020-COVID-19Resources Raisi-Estabragh, Z., McCracken, C., Bethell, M. S., Cooper, J., Cooper, C., Caulfield, Munroe, P., Harvey, N., Petersen, S. E. (2020). Greater risk of severe COVID-19 in Black, Asian and minority ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank. Journal of Public Health, 42(3), 451–460. https://doi. org/10.1093/pubmed/fdaa095 Robinson, D. (2020, April 10). Dozens of NY’s hospitals closed. Then COVID-19 hit. Now marginalized patients are dying. Here’s why. Lohud. https://www.lohud.com/story/news/coronavirus/2020/04/10/ why-ny-hospital-closures-cutbacks-made-covid-19-pandemicworse/5123619002/ Sauter, S., Murphy, L., Colligan, M., Swanson, N., Hurrell, J., Scharf, F., Grub, R.S.P., Goldenhar, L., Alterman, T., Johnston, J., Hamilton, A., Tisdale, J. (1999). Stress at work. NIOSH. https://www.cdc.gov/niosh/ docs/99-101/pdfs/99-101.pdf?id=10.26616/NIOSHPUB99101 Shah, S., & Kocher, B. (2020, April 24). What if we gave hospitals real incentives to prepare for the next pandemic? Health Affairs. https:// www.healthaffairs.org/do/10.1377/hblog20200422.253713/full/ Shaukat, N., Ali, D. M., Razzak, L. (2020). Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. International Journal of Emergency Medicine, 13(1), 1–8. https://doi. org/10.1186/s12245-020-00299-5 Society of Critical Care Medicine (2020, March 26). Consensus statement on multiple patients on ventilators. https://www.sccm.org/Disaster/ Joint-Statement-on-Multiple-Patients-Per-Ventilator Sun, N., Wei, L., Shi, S., Jiao, D., Song, R., Ma, L., Wang, H., Wang, C., Wang, Z., You, Y., Liu, S., Wang, H. (2020). A qualitative study on the psychological experience of caregivers of COVID-19 patients. American Journal of Infection Control, 48(6), 592–598. https://doi. org/10.1016/j.ajic.2020.03.018

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Vnenchak, K., Sperling, M. L., Kelley, K., Petersen, B., Silverstein, W., Petzoldt, O., Cooper, L., Kowalski, M. O. (2019). Dedicated education unit improving critical thinking and anxiety: a longitudinal study. Journal for Nurses in Professional Development, 35(6), 317–323. https://doi.org/10.1097/NND.0000000000000586 WorldOMeter. (2020, September 23). https://www.worldometers.info/ coronavirus/?utm_campaign=homeAdvegas1

emergency department staff: A systematic review protocol. JBI Database of Systematic Reviews & Implementation Reports, 17(4), 513–519. https://doi.org/10.11124/JBISRIR-2017-003955 Zheng, Z., Gu, S., Lei, Y., Lu, S., Wang, W., Li, Y., & Wang, F. (2016). Safety needs mediate stressful events induced mental disorders. Neural Plasticity, (1), 1–6. https://doi.org/10.1155/2016/8058093

Xu, H., Kynoch, K., Tuckett, A., Eley, R., & Newcombe, P. (2019). Effectiveness of interventions to reduce occupational stress among

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Appendix A

NYSNA COVID-19 Member Survey

1. Please enter your full name. 2. Please enter your e-mail address. 3. Is your facility public sector or private sector? 4. Are you an RN, NP or other (please specify)? 5. What setting do you currently work in? 6. If you work in a hospital setting, what is your specialty area? 7. How would you rate your employer’s implementation of plans for protecting employees during the Coronavirus/COVID-19 epidemic? 8. How would you rate your employer’s communication to staff regarding COVID-19 during this period of time? 9. Has your employer provided information to you regarding how to recognize and respond to possible cases of COVID-19? 10. Has your employer instituted COVID-19 screening for all patients with fever and/or respiratory symptoms? 11. Does your employer have airborne infection isolation rooms (“negative pressure rooms”) available on your unit? 12. How many airborne infection isolation rooms are available? 13. Do you have access to the following personal protective equipment (PPE) for airborne precautions on your unit? Please select each PPE item you currently have access to (gloves, impermeable gown, face shield/goggles, N95 respirators, PAPR respirators. 14. Have you been fit tested for the use of your N95 respirator? 15. Is the correct size based on your fit test available for your use on the unit? 16. Are staff currently required, or will be required, to reuse N95 respirators while caring for COVID-19 patients? 17. If COVID-19 patients are cared for in your facility, is there a policy calling for dedicated staff caring only for those patients? 18. Does your employer have a plan to address additional staff needed due to dedicated staff (1:1) for COVID-19 patients? 19. Does your employer have a plan to address additional staff needed to screen COVID-19 patients, in advance of their visit and/or when they arrive? 20. Does your employer have a plan to cover staff who may have to be quarantined during the epidemic? 21. Are you confident your employer has sufficient PPE stock on hand to protect staff if there is a rapid surge in patients with possible COVID-19 infections? 22. Have you been trained on safely donning and doffing (putting on and taking off) PPE in the previous year? 23. Does your employer have a policy to address employees with suspected or known exposure to COVID-19? 24. Does your employer have a policy to ensure that any staff forced to be quarantined are paid for their time off work? 25. Has your employer implemented any measures around screening patients for symptoms or travel/exposure history, such as calling patients prior to coming to the facility? 26. To the best of your knowledge, have any patients at your facility been identified as possible coronavirus cases? 27. If patients at your facility were identified as possible coronavirus cases, were any staff, patients, or visitors exposed during the care of these patients?

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Appendix B

NYSNA COVID-19 Patient Care Survey

1. What is your name? 2. What facility do you work in? 3. What is your home unit? 4. While treating COVID-19 patients, are you working on the same unit where you normally work? 5. Is the unit you are working on while treating COVID-19 patients utilizing team nursing, or are nurses being paired together to address competency? 6. Do you find team nursing or nurse pairing supports safer nursing practice? Check all that apply. 7. Do you find that team nursing or nurse pairing supports decreasing exposure to the coronavirus? 8. Do you find that team nursing or nurse pairing decreased stress of the nurses involved? Check all that apply. 9. When treating COVID-19 patients, did you keep IV pumps outside of patient rooms? Check all that apply. 10. When treating COVID-19 patients, did your unit prone patients? Check all that apply). 11. What were the most effective nursing and medical treatments that you found made a difference in COVID-19 patient outcomes? 12. How stressful was it treating patients with a diagnosis where so little is known, including treatment options? 13. How stressful was it working with the possibility the patient will suddenly deteriorate? 14. How stressful was it working with a lack of PPE? 15. How stressful was it working in a specialty area you are not used to? 16. How stressful was it working with the possibility of contracting COVID-19? 17. How stressful was it working with medications you are not familiar with? 18. How stressful was it working with ventilators? 19. How stressful was it working with nurses who are not interested in team nursing? 20. How stressful was it having too many of your co-workers get sick? 21. How stressful was it having too many patient deaths? 22. Which of the working conditions below would you rate as the most stressful? 23. Which of the working conditions below would you rate as the least stressful? 24. Did your facility provide patients with an iPad or other device which enabled staff to communicate with patients from outside of the patient’s room? Check all that apply. 25. What is your name? 26. What facility do you work in? 27. What is your home unit? 28. While treating COVID-19 patients, are you working on the same unit where you normally work? 29. Is the unit you are working on while treating COVID-19 patients utilizing team nursing, or are nurses being paired together to address competency? 30. Do you find that team nursing or nurse pairing supports safer nursing practice? Check all that apply. 31. Do you find that team nursing or nurse pairing supports decreasing exposure to the coronavirus? 32. Do you find that team nursing or nurse pairing decreased stress of the nurses involved? Check all that apply. 33. When treating COVID-19 patients, did you keep IV pumps outside of patient rooms? Check all that apply. 34. When treating COVID-19 patients, did your unit prone patients? Check all that apply. Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Appendix B (continued)

NYSNA COVID-19 Patient Care Survey 35. What are the most effective nursing and medical treatments that you found made a difference in COVID-19 patient outcomes? 36. How stressful was it treating patients with a diagnosis where so little is known, including treatment options? 37. How stressful was it working with the possibility the patient will suddenly deteriorate? 38. How stressful was it working with a lack of PPE? 39. How stressful was it working in a specialty area you are not used to? 40. How stressful was it working with the possibility of contacting COVID-19? 41. How stressful was it working with medications you are not familiar with? 42. How stressful was it working with ventilators? 43. How stressful was it working with nurses who are not interested in team nursing? 44. How stressful was it having too many of your coworkers get sick? 45. How stressful was it having too many patient deaths? 46. Which of the working conditions below would you rate as the most stressful? 47. Which of the working conditions below would you rate as the least stressful? 48. Did your facility provide patients with an iPad or other device which enabled staff to communicate with patients from outside of the patient’s room? Check all that apply.

Journal of the New York State Nurses Association, Volume 48, Number 1

Nurses Unions Can Help Reduce Stress, Burnout, Depression, and Compassion Fatigue During the COVID-19 Pandemic, Part 3

Appendix C

NYSNA COVID-19 Education Zoom Session Participant Survey

1. What is your name? 2. What is your nursing specialty practice? 3. Which program(s) did you attend? 4. Please answer the following questions using the rating scale. a. How well did the educational program meet your own learning needs? b. How interesting did you find the program? c. How relevant did you find the content provided? d. How would you rate the design of the program? e. How would you rate the style of the presenters? f. How would you rate the knowledge of the presenters? g. How would you rate the pace of the program? h. How valuable were the topics covered? 5. Has the program had a positive effect (check all that apply). 6. Please describe how your practice regarding the COVID patient has changed as a result of taking this program. 7. Looking back, do you think that the program has enhanced: a. Your confidence working with the COVID patient? b. Your working as a multidisciplinary team member? c. Your clinical practice of the COVID patient to the benefit of the patient? 8. Would you recommend any changes and/or additions to the program? 9. Are there any other comments you would like to make?

Journal of the New York State Nurses Association, Volume 48, Number 1

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic Marcelina Stewart, MSN, APRN, AGNP-C Marie Cox, DNP, RN, ANP-C

n Abstract The severe opioid dependence and addiction crisis has penetrated all geographical and socioeconomic levels of today’s society. For decades, the opioid epidemic has been considered a critical public health problem in the United States. The crisis began with inadequate pain management requiring physicians to manage and treat pain aggressively leading to overprescribing of the medication, resulting in misuse and addiction. Drug overdose is the leading cause of injury death in America, and nurse practitioners (NPs) are charged with the responsibility of educating patients and the public about the present opioid epidemic. Currently, about 2.1 million individuals suffer from opioid use disorders (OUD) due to severe pain. Significant gaps in medication-assisted treatment (MAT) were identified. Additionally, decentralized resources and lack of overall awareness of what MAT entails can keep individuals from seeking treatment. The Comprehensive Addiction and Recovery Act (CARA) was signed into law in 2016 to address the increasing incidence of opioid use disorder. The goal of CARA is to expand prevention and education efforts and treatment and recovery to address the opioid epidemic. A current literature review was performed using the following databases: CINAHL, ProQuest, PubMed Central, and EBSCOhost. The review of literature was searched for barriers impacting the NP in combating the opioid epidemic, of which several barriers were identified. Some of these barriers include outdated stereotypes, racism, lack of MAT availability, bureaucratic and regulatory hurdles, lack of education, and insufficient coverage from both public and private insurers. NPs play a crucial role in identifying those with opioid addiction and utilizing an empathetic, nonjudgmental, and caring approach. It is vital for NPs to be well educated and equipped to assess patients trapped in the thick of opioid abuse, evaluating each patient’s individual circumstance to get them the assistance they need. They have an opportunity to educate patients on the function of pain prescription in their care, incorporating pain prescription alternatives, and reasons why non-opioids are a better option. Patient utilization of prescription drugs should be closely monitored by the NP to avoid overreliance or possible addiction, referring severe pain patients to a pain control expert or center. In the United States, the opioid epidemic is considered a serious public health problem, ensuing from the amplified use of prescribed or illegal consumption of recommended and unrecommended opioid medications (Kolodny et al., 2015). Drug overuse is a leading cause of death in America, and NPs are responsible for educating the entire community. In 2016, primary care clinicians prescribed 45% of opioids and pharmacies dispensed 215 million opioid prescriptions, which contributed to 40% of overdose deaths from opioids (Tong et al., 2019). Medication such as hydrocodone, morphine, or oxycodone to control pain are usually a significant element of treatment for those suffering from extreme pain, but they have severe side effects. According to Moore (2016), studies reveal that more than two million individuals tend to abuse their recommended pain relievers because of addictive effects. Just a fraction of those individuals get treatment as a result, drug overdoses contribute to the majority of the deaths in America Marcelina Stewart, MSN, APRN, AGNP-C 1,2, and Marie Cox, DNP, RN, ANP-C 1 1 Adelphi University College of Nursing and Public Health; 2Rogosin Institute Auburndale Dialysis Center 52

Journal of the New York State Nurses Association, Volume 48, Number 1

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

in comparison to other chronic conditions. Opioid misuse and addiction are an ongoing public health problem. In 2016, nearly 100 million individuals had pain and a large number of them were prescribed opioids for pain relief (Stoicea et al., 2019). Over 20 million patients who are prescribed opioids abuse them and approximately two million become addicted (Gostin et al., 2017). The CARA was signed into law in 2016 to address the increasing incidence of opioid use disorder, which affects millions of Americans (Moore, 2019). Furthermore, this new law acknowledges the advantage of NPs in combating the opioid crisis. NPs can seek a federal waiver, which allows them to prescribe anti-addiction drugs such as buprenorphine to prevent withdrawal symptoms (Moore, 2019). NPs are positioned as a crucial provider in the battle to solve the opioid crisis. This paper will focus on the role of the NP in combating the opioid crisis and examine some of the barriers that NPs face in this effort. Keywords: n urse practitioners (NPs), opioid treatment, Comprehensive Addiction and Recovery Act (CARA), medicationassisted treatment (MAT)

Background Nurse practitioners (NPs) are faced daily with the issue of opioid misuse in the United States. The impact of this epidemic tends to affect all persons and families across their lifespan, whether due to the despair on the family unit in dealing with the addiction or the person directly using the drug itself (Jackson & Lopez, 2018). Patients of low socioeconomic class tend to be at higher risk for opioid addiction (Altekruse et al., 2020). Patients suffering from substance abuse problems are present in every area of nursing practice, giving NPs the opportunity to establish rapport through the nurse-patient relationship and provide a secure and trusting platform for patients to reveal their drug use. NPs are generally positioned to make huge impacts in reducing opioid overdose in specialty practices and primary care (Jackson & Lopez, 2018).

Barriers Impacting the NP in Combating the Opioid Epidemic Obsolete laws in some states prevent NPs from using their training and education to combat the opioid epidemic and also decrease access to care for patients experiencing opioid addiction (Moore, 2019). It has already been established that eliminating legislative restrictions for NPs to provide independent care can improve patient results, and where addiction is concerned, it means saving lives. NPs are available and ready to lead, but some barriers prevent them from practicing their role in combating

Patients suffering from substance abuse problems are present in every area of nursing practice, giving NPs the opportunity to establish rapport through the nurse-patient relationship and provide a secure and trusting platform for patients to reveal their drug use.

this particular crisis such as stereotypes and racial bias, lack of access to medication-assisted treatment (MAT), bureaucratic and regulatory hurdles, lack of education, and insufficient coverage from both public and private insurers (Santoro & Santoro, 2018).

Stereotypes and Racial Bias Opioid dependence and addiction have penetrated all geographical and socioeconomic levels of today’s society. However, White Americans have been disproportionately impaired by the opioid epidemic, due to racism and stereotyping. The crisis started when chronic pain was perceived as undertreated and healthcare providers were assured by pharmaceutical companies that opioids were safe when used to relieve pain. As a result, physicians began to prescribe opioids to their patients as the answer to pain relief, which resulted in the drugs being proliferated among patients, including children (Vadivelu et al., 2018). Studies reveal that individuals who abuse opioids get their supply by going through their parents’ cabinets, the black market where patients illegally purchase extra pills, and friends and family members giving them as gifts (Salmond & Allread, 2019). Recent research also reveals that healthcare providers are more hesitant to prescribe painkillers to people of minority groups such as Blacks because they believe that Black patients are less susceptible to pain or are more likely to abuse and sell the drugs (Om, 2018). In some unintended ways, this protected minority patients from the opioid outbreak that more severely affected approximately 90% of Whites (Om, 2018). In turn, this led to Whites abusing prescription synthetic opioids, heroin, and cocaine, creating a wave of addiction and dangerous overdoses (Santoro & Santoro, 2018). On the other hand, there are reports that class also plays a role in opioid misuse. For instance, the epidemic has also been linked to patients from lower socioeconomic backgrounds (Altekruse et al., 2020). The stigma of seeking treatment for opioid addiction is embedded in many communities across the United States and world. This societal factor tends to discourage individuals from accessing care, as they are afraid of being isolated or seen differently by their communities. Stigmatization is a barrier for NPs and leads to difficulties in reaching out to the affected individuals. To handle this setback, educational campaigns should be directed toward addicted patients informing them that it is okay to seek care, addiction is not a personal fault, and anyone can be affected. Therefore, public education campaigns should be used to encourage affected

Journal of the New York State Nurses Association, Volume 48, Number 1

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

An obstacle to NPs is the inability to provide treatment due to limited resources, and inability to prescribe MAT and to obtain a waivered physician.

individuals to talk and seek help as well as educating the public to aid them rather than criticizing them (Corrigan & Nieweglowski, 2018).

Lack of Access to Medication-Assisted Treatment Medication-assisted treatment (MAT) has proven to be an effective treatment in assisting individuals to recover from opioid use disorder (OUD), but the disparity is that not everyone gets it. MAT is a treatment program that includes a combination of medication with counseling and therapy to aid in the treatment of OUD. The MAT program focuses on prescribing buprenorphine, which is a medication that lowers the potential for misuse of opioids, together with educational, behavioral, and medical forms of treatment (Moore, 2019). About 30 million Americans reside in counties where doctors and NPs do not have the necessary federal waiver to prescribe buprenorphine (Andrilla et al., 2018). The waiver consists of completing a 24-hour course to train providers on how to identify individuals with OUD and prescribe the recommended medication such as buprenorphine (Gardenier et al., 2020). Buprenorphine is one of the most accessible alternatives because it can be prescribed and dispensed in the primary care setting, unlike methadone treatment (Moore, 2019). The lack of MAT availability, shortage of providers such as NPs, physician assistants (PAs), and physicians, as well as strict laws and high-cost fees makes it harder for anyone to start treatment and continue to finish the course of therapy without interruption. Different eligibility problems facing the patient also limit access to MAT options (Gardenier et al., 2020). Decentralized resources, a lack of overall awareness of what MAT entails, and misinformation can keep individuals from seeking help. In addition, provider education and training for the MAT waiver can delay a life-threatening treatment for the individual suffering from OUD.

Bureaucratic and Regulatory Hurdles On the verge of the worsening opioid epidemic and an uncontrollable increase of drug misuse and overdose, an immediate call to action has been reported in the literature. Medical doctors, PAs, and NPs are trained individuals to diagnose, treat, and manage clients with OUD. An obstacle to NPs is the inability to provide treatment due to limited resources, and inability to prescribe MAT and to obtain a waivered physician (Moore, 2019). The Centers for Disease Control and Prevention (CDC) produced a guideline recommending shorter durations for opioid prescriptions and the utilization of non-drug pain management treatment. These guidelines were created to control opioid misuse and overdose allowing patients to improve quality of life while living with chronic pain. It was suggested that opioid doses should be kept lower than the average 90 milligrams of morphine to prevent dependence and immediate harm. Unfortunately, the CDC did not 54

provide a specific guideline on how to care for those already receiving high doses and the recommended threshold. Nonetheless, the CDC encourages healthcare providers to approach clients who have reached or who are taking more than the maximum dosage, so they can be assessed for a decrease in dosage (Dowell et al., 2016). Although the CDC guidelines for dose-limiting opioid treatment could greatly benefit some patients, it may destabilize others and most likely encourage the abuse of heroin or other addictive drugs. In other words, these guidelines place numerous patients suffering from severe pain at risk for seeking pain medication from the black market or from family and friends, placing them at danger for overdose because they would lose access to their current prescribed dosage. Overall, the drug distributors, manufacturers, chain drug stores, and wholesalers have considerable influence in safeguarding their interests over actions taken at the height of an opioid crisis. The drug manufacturers and drug stores, for instance, join forces to mislead doctors and customers of the effectiveness of opioid drugs (Hoffman, 2020). Notably, drug industry professionals and experts blame the origins of the opioid epidemic on the over-recommending of pain pills by physicians, which is compounding the problem by shifting blame.

Lack of Education The American opioid epidemic has taken the lives of many individuals of all levels of education. However, the death tolls have increasingly been more focused among those with lower educational levels. Studies have revealed that more-literate adults in America usually live longer than their less-literate counterparts (Altekruse et al., 2020). Furthermore, individuals with lower educational levels experience restricted job chances and poor economic possibilities, thus leaving them prone to despair, drug addiction, and depression. Given that the majority of NPs practice in primary care, they are generally in a position to encounter patients who are affected by social determinants of health and lack educational awareness about opioid addiction. NPs can educate these patients and their families about the advantages and risks of pain management and alternative treatments. As teachers and frontline providers, NPs are in a unique position to help patients with non-opioid pain management, including interventions geared towards discussion on rehabilitative therapy and counseling (Denis, 2019).

Insufficient Coverage From Both Public and Private Insurers There is a distinction between the number of individuals in need of addiction treatment in America and those who receive it. In 2016, over two million individuals older than the age of 12 required substance abuse treatment (Lipari et al., 2016). Unfortunately, about one million qualified individuals who abuse opioids are unable to access the necessary treatment (Vashishtha et al., 2017). Most individuals go untreated for various reasons: reluctance due to certain beliefs, financial hardship, or unavailability of MAT providers (Cadet & Tucker, 2019). Another obstacle is the need of prior authorization by Medicaid and private insurance to approve the expenses of OUD (Mark et al., 2020). However, Medicaid developed a plan for some individuals diagnosed with OUD, especially for those living in rural areas. Payments are geared to rehabilitation and MAT. Though some patients are qualified for an outpatient program, a copay may prevent those individuals from seeking care (Ostling et al., 2018). The insurance company ultimately decides on the importance of

Journal of the New York State Nurses Association, Volume 48, Number 1

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

prior authorization allowing clinics to treat individuals with OUD. A delay in treatment due to the need of prior authorization can delay treatment claiming the lives of many. Notably, insurance that covers MAT pays for only one of the three approved MAT medications, that is, naltrexone, methadone, or buprenorphine (Moore, 2019).

they will be allowed to increase their patient volume to 100 (Zoorob, Kowalchuk, & Mejia de Grubb, 2018). A critical aspect of overcoming these barriers is to allow healthcare providers to expand the patient limit. So, in 2016, a pilot program was created permitting NPs and PAs to treat a maximum of 275 individuals until 2021. Also, legislation will allow NPs to apply for a second waiver until October 2023 (Ghertner, 2019).

Overcoming the Barriers Impacting NPs in Combating the Opioid Epidemic

Together with MAT services, all NPs as direct caregivers, educators, patient supporters, and care coordinators play a significant role in solving the opioid epidemic by assisting patients and their families to comprehend the risks and gains of pain treatment alternatives. Many states acknowledge CARA (2016) allowing NPs to practice without restriction, but there are 28 states that prevent NPs from prescribing buprenorphine without the collaboration of waivered physicians. Legislators must create a stronger approach to allow NPs to practice without restriction or facilitate the collaboration of waivered physicians (Jackson & Lopez, 2018).

More than 1,000 individuals visit the emergency room daily because of opioid abuse and about 90% die from it (Jackson & Lopez, 2018). Approximately one third of persons who used opioids also abuse alcohol as a result, which increases the risk of opioid overdose and emergency department visits. When individuals combine drugs and alcohol, they are in danger of irreversible injury or even death as their breathing tends to slow down or come to a complete halt (Cochran et al., 2017). Access to effective opioid addiction treatment is the missing piece in America’s unstable battle against the opioid epidemic. The NPs who treat and prescribe medications in the American healthcare system are educated and provide holistic care in their utilization of opioids to treat pain. They are also educated to consider non-opioid therapies and medicines (Gardenier et al., 2020). Prescribers who have undertaken the process and education to obtain a Drug Enforcement Administration (DEA) waiver to prescribe and participate in a MAT program, are restricted to prescribe buprenorphine to treat no more than 30 patients and after the first year

Many states acknowledge CARA (2016) allowing NPs to practice without restriction, but there are 28 states that prevent NPs from prescribing buprenorphine without the collaboration of waivered physicians. Legislators must create a stronger approach to allow NPs to practice without restriction or facilitate the collaboration of waivered physicians.

Conclusion The opioid epidemic is a public health emergency that is tasking the lives of many Americans. NPs are working hard to aid in curbing the growing crisis in the United States. With increased cases of opioid abuse, NPs play a crucial role in identifying those with opioid addiction and utilizing an empathetic, nonjudgmental, and caring approach. It is vital for NPs to be well educated and equipped to notice patients trapped in the thick of opioid abuse, evaluating each patient’s individual circumstance to get them the assistance they need. They have an opportunity to educate patients in their care on the function of pain treatment, incorporating pain prescription alternatives and reasons why non-opioids are a better option. Patient utilization of opioids should be closely monitored by NPs and other providers to avoid overreliance or possible addiction, and for referring severe pain patients to a pain control expert or center. It is crucial for legislators to consider the usefulness of NPs to overturn this crisis. Investing in educating prospective advanced practice nurses can be the key to the solution of this crisis. For example, the American Society of Addiction Medicine has partnered with the American Association of Colleges of Nursing to increase substance use disorder education for nurse practitioners. For any measure to be effective, the nursing community should support it wholeheartedly and engage in public and private discussions related to the consequences of opioid misuse; this can be a stepping stone to decreasing opioid abuse and opioid overdose related deaths in the United States.

Journal of the New York State Nurses Association, Volume 48, Number 1

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

n References Altekruse, S. F., Cosgrove, C. M., Altekruse, W. C., Jenkins, R. A., & Blanco, C. (2020). Socioeconomic risk factors for fatal opioid overdoses in the United States: Findings from the mortality disparities in American communities study (MDAC). PLoS One, 15(1) http://dx.doi.org. libproxy.adelphi.edu/10.1371/journal.pone.0227966

Lipari, R. N., Park-Lee, E., & Van Horn, S. (2016, September 29). America’s need for and receipt of substance use treatment in 2015. SAMHSA —Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/report_2716/ ShortReport-2716.pdf

Cadet, M. J., & Tucker, L. (2019). NP role in medication-assisted treatment for opioid use disorder: Combine medication and counseling with shared decision-making to treat addiction. American Nurse Today, 14(1), 8–13.

Mark, T. L., Parish, W. J., & Zarkin, G. A. (2020). Association of formulary prior authorization policies with buprenorphine-naloxone prescriptions and hospital and emergency department use among Medicare beneficiaries. JAMA Network Open, 3(4), e203132. https:// doi.org/10.1001/jamanetworkopen.2020.3132

Cochran, G., McCarthy, R., Gordon, A. J., & Tarter, R. E. (2017). Opioid medication misuse among unhealthy drinkers. Drug and Alcohol Dependence, 179, 13–17. https://doi.org/10.1016/j. drugalcdep.2017.06.013 Corrigan, P. W., & Nieweglowski, K. (2018). Stigma and the public health agenda for the opioid crisis in America. International Journal of Drug Policy, 59, 44–49. https://doi.org/10.1016/j.drugpo.2018.06.015 Denis, A. M. (2019). Managing opioid use disorder: The nurse practitioner addressing the challenge. Medsurg Nursing, 28(5), 281–286, 316. http://libproxy.adelphi.edu/login?url=https://search-proquest-com. libproxy.adelphi.edu/docview/2306443251?accountid=8204 Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624. https://doi.org/10.1001/jama.2016.1464 Gardenier, D., Moore, D. J., & Patrick, S. R. (2020). Have waivers allowing nurse practitioners to treat opioid use disorder made a difference in the opioid epidemic? The Journal for Nurse Practitioners, 16(3), 174–175. https://doi.org/10.1016/j.nurpra.2019.12.001 Ghertner, R. (2019). U.S. trends in the supply of providers with a waiver to prescribe buprenorphine for opioid use disorder in 2016 and 2018. Drug and Alcohol Dependence, 204, 107527. https://doi.org/10.1016/j. drugalcdep.2019.06.029 Gostin, L. O., Hodge, J. G., & Noe, S. A. (2017). Reframing the opioid epidemic as a national emergency. JAMA, 318(16), 1539. https://doi. org/10.1001/jama.2017.13358 Jackson, H. J., & Lopez, C. M. (2018). Utilization of the nurse practitioner role to combat the opioid crisis. The Journal for Nurse Practitioners, 14(10), e213–e216. https://doi.org/10.1016/j.nurpra.2018.08.016 Hoffman, J. (2020, May 27). Big pharmacy chains also fed the opioid epidemic, court filing says. The New York Times. https://www. nytimes.com/2020/05/27/health/opioids-pharmacy-cvs-litigation.html Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36(1), 559–574. https://doi.org/10.1146/ annurev-publhealth-031914-122957

Moore, D. J. (2019). Nurse practitioners’ pivotal role in ending the opioid epidemic. The Journal for Nurse Practitioners, 15(5), 323–327. Om, A. (2018). The opioid crisis in black and white: The role of race in our nation’s recent drug epidemic. Journal of Public Health, 40(4), e614–e615. https://doi.org/10.1093/pubmed/fdy103 Ostling, P. S., Davidson, K. S., Anyama, B. O., Helander, E. M., Wyche, M. Q., & Kaye, A. D. (2018). America’s opioid epidemic: a comprehensive review and look into the rising crisis. Current Pain and Headache Reports, 22(5), 1–7. Salmond, S., & Allread, V. (2019). A population health approach to America’s opioid epidemic. Orthopaedic Nursing, 38(2), 95–108. https://doi.org/10.1097/nor.0000000000000521 Santoro, T. N., & Santoro, J. D. (2018). Racial bias in the U.S. opioid epidemic: A review of the history of systemic bias and implications for care. Cureus. https://doi.org/10.7759/cureus.3733 Stoicea, N., Costa, A., Periel, L., Uribe, A., Weaver, T., & Bergese, S. D. (2019). Current perspectives on the opioid crisis in the U.S. healthcare system. Medicine, 98(20), e15425. https://doi.org/10.1097/ md.0000000000015425 Tong, S. T., Hochheimer, C. J., Brooks, E. M., Sabo, R. T., Jiang, V., Day, T., Rozman, J. S., Kashiri, P. L., & Krist, A. H. (2019). Chronic opioid prescribing in primary care: Factors and perspectives. The Annals of Family Medicine, 17(3), 200–206. https://doi.org/10.1370/afm.2357 Vadivelu, N., Kai, A. M., Kodumudi, V., Sramcik, J., & Kaye, A. D. (2018). The opioid crisis: A comprehensive overview. Current Pain and Headache Reports, 22(3). https://doi.org/10.1007/s11916-018-0670-z Vashishtha, D., Mittal, M. L., & Werb, D. (2017). The North American opioid epidemic: Current challenges and a call for treatment as prevention. Harm Reduction Journal, 14(1). https://doi.org/10.1186/ s12954-017-0135-4 Zoorob, R., Kowalchuk, A., & Mejia de Grubb, M. (2018). Buprenorphine Therapy for Opioid Use Disorder. American Family Physician, 97(5), 313–320.

Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic Marilyn B. Klainberg, EdD, RN, NYAM Fellow Maureen C. Roller, DNP, RN, ANP-BC Deborah Ambrosio-Mawhirter, EdD, RN, NYAM Fellow Jacqueline P. Johnston, PhD, RN, ANP-C Clarilee Hauser, PhD, RN R. David Parker, PhD Susan M. Neville, PhD, RN, CDP, CADDCT, AACN Wharton Fellow

n A bstract

Background: Sleep is important for physical and emotional health. Nursing students attend a rigorous program of study, which may impact sleep and academic performance. Purpose: Explore the impact of rigorous schedules and the COVID-19 pandemic on sleep habits and academic performance of nursing students. Method: A descriptive quantitative comparative study. Results: Pre-study Medical Surgical 2 grades from fall 2019 (89.66%) were compared to grades from spring 2020 (89.00%). Fall 2019 capstone student theory grades were 77%–100% pre-pandemic and 80%–100% in the spring 2020 during the pandemic. Students’ good sleep quality in the fall of 2019 was 9.8%, and increased to 37.4% in the spring of 2020. Pre-pandemic outside school stressors were 75.0% and 91.5% during the pandemic. Conclusion: Spring semester of 2020 revealed increased stressors in students, yet sleep quality improved with no effect on academic performance. Grades in both semesters were similar and not impacted. Thus, despite increased stressors in spring 2020, pandemic sleep quality improved. Keywords: sleep, COVID-19, pandemic, Pittsburgh Sleep Quality Index (PSQI)

Marilyn B. Klainberg, EdD, RN, NYAM Fellow 1; Maureen C. Roller, DNP, RN, ANP-BC 1; Deborah Ambrosio-Mawhirter, EdD, RN, NYAM Fellow; Jacqueline P. Johnston, PhD, RN, ANP-C 1; Clarilee Hauser, PhD, RN 1; R. David Parker, PhD 2; and Susan M. Neville, PhD, RN, CDP, CADDCT, AACN Wharton Fellow1 1 College of Nursing and Public Health, Adelphi University; 2Center on Alcohol & Addiction Studies, University of Alaska Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic

Introduction

Summary of Literature

Background

Nursing students, due to rigorous academic and personal schedules, may develop poor sleep habits that affect their student experience and carry over into professional practice. In the fall of 2019, the American College Health Association National College Health Assessment (ACHA-NCHA) survey of 30,084 students from 58 institutions of higher education in the United States found that 49.8% of students reported less than 7 hours of sleep per night on weekdays, 48.8% reported 7 to 9 hours of sleep, and 1.5% reported greater than or equal to 10 hours of sleep. Of these students, 44.3% reported feeling tired or sleepy during the day 3 to 5 times a week 33.8% reported the same 6 to 7 times a week.

The National Institute of Health (NIH) (2020) describes sleep as a complex biological process. Over the past two decades, researchers have noted changes and decreased hours of sleep among college students. It is common practice for college students to sacrifice sleep to study or to socialize. Sleep is an important aspect of health, quality of life, safety, and academic performance. College students often disregard the potential benefits of sleep and lack formal education regarding sleep hygiene practices (Detrich et al., 2016). Sleep cycles roughly follow a 24-hour cycle of circadian rhythms. In addition to a person’s biological needs, one’s need for sleep is influenced by the environment and societal norms (Goel et al., 2013). Therefore, one’s sleep health is multidimensional and factors include both the quality and the amount of sleep one requires (Billings et al., 2020). Changes in sleep patterns or lack of sleep disrupt an individual’s circadian rhythm and may impact their mental and physical health. Poor sleep habits among college students are often due to a variety of causes, including school requirements, work, and socialization. This may be particularly true among pre-licensure nursing students due to the rigor of clinical and laboratory work required as part of their nursing preparation (Rosso et al., 2019). The original purpose of this study was to explore sleep habits of nursing students in order to determine the impact of rigorous schedules on their sleep habits and patterns. However, a worldwide pandemic occurred during data collection, suggesting an additional second purpose: to explore the impact of the COVID-19 pandemic on the sleep habits of nursing students and any correlation with academic performance.

Theoretical Framework Sleep is a basic human need addressed by multiple theorists’ models (Maslow, 1943; Nightingale, 1992; Henderson, 1996; & Pender et al., 2010). Nola Pender’s revised health promotion model (Pender et al., 2010) observes that individuals have unique experiences that result in not only the actions they take, but also their outcomes. Multiple variables of behavior promote motivation and are significant to these individuals. The desired outcome in health-promoting behavior should result in improved health, enhanced functional ability, and better quality of life.

According to the American Academy of Sleep Medicine and Sleep Research Society, “Sleeping less than 7 hours per night on a regular basis is associated with adverse health outcomes…impaired immune function… impaired performance, increased errors, and a greater risk for accidents” (Watson et al., 2015, p. 843). This can significantly impact a nursing student’s academic and clinical performance. In a review of the literature, a study by Lund et al. (2010) of sleep patterns and predictors of disturbed sleep in a large population of college students found that insufficient sleep in high school students extended to college students. Total hours were similar, but bedtimes and rest times shifted later by 90 minutes for both weekdays and weekends. The delay of bedtimes and later rise times continued into young adulthood. The most significant factor demonstrated by these students was low sleep quality and perceived stress. Tension and stress predicted 24% of the variance in their Pittsburgh Sleep Quality Index (PSQI) score. The authors identify that perceived stress could be predisposing, precipitating, and perpetuating factors in sleep difficulties. Variables such as erratic schedules and high stress events such as exam times influence these issues. The authors identify the neuroendocrine hyperactivity axis during this developmental stage as another contributor to hyper-arousal observed in delayed sleep and increased anxiety and depression. This can also contribute to the poor coping strategies seen in handling stressful events, common in this population and precipitating bouts of sleep difficulty accompanied by rumination and worry. College students

Pender’s model relies on multiple assumptions involving the individual’s ability to regulate their own behavior, interact with their environment, and change within it, and it assumes that change is a continuous factor throughout their life. Pender states that individuals will benefit from a change of behavior if they anticipate that there will be a positive outcome. Perceived barriers can be a constraint on commitment to change, while an increase in self-efficacy to execute a given behavior increases the likelihood of behavior change. Health-protecting behaviors and activities such as sleep can lead to an improved quality of life (Pender et al., 2010). The authors investigated academic performance and sleep quality and the impact of the rigorous schedules on nursing students. Additionally, the unexpected impact of COVID-19 restrictions affected the students’ health -protecting behaviors in this study. 58

Journal of the New York State Nurses Association, Volume 48, Number 1

In the fall of 2019, the American College Health Association National College Health Assessment (ACHA-NCHA) survey of 30,084 students from 58 institutions of higher education in the United States found that 49.8% of students reported less than 7 hours of sleep per night on weekdays, 48.8% reported 7 to 9 hours of sleep, and 1.5% reported greater than or equal to 10 hours of sleep.

Impact of Sleep on Nursing Students in the Era of a Pandemic

consistently get poor quality sleep and are at risk for problems such as mood and substance use disorders. Research by Gaultney (2010) on a population of 1,845 college students demonstrated an average of 6.79 hours of sleep on a typical school/ work night and 9.3 hours on a non-school/non-work night, resulting in a discrepancy of 2.49 hours of sleep between school/work nights and nonschool/non-work nights. Among the participants, 19% worried much or very much about whether they got enough sleep. Students who reported no sleep issues had higher grade point averages (GPAs) than those with at least one sleep disorder (M = 2.65, SD 0.99), F(1, 1842) = 15.17, p < .01. Those who indicated they were “evening people” rather than “morning people” also had lower GPAs. The subjects’ GPAs were correlated with the amount of sleep prior to schoolwork (r = 0.12, p < 0.01) and with difference score (r = -0.06, p < 0.05) indicating those who reported consistent sleep schedules had higher GPAs. The researcher noted that 12% of the overall population was identified to experience a sleep disorder, including narcolepsy (16%), insomnia (12%), and restless leg syndrome or periodic limb movement disorder (8%). In a recent qualitative study, Wang et al. (2020) found that sleep patterns among college students in the United States were disrupted during the COVID-19 pandemic. The study noted irregular sleep patterns such as inconsistent bedtimes and wake times day to day. Students in the study also reported that, although they were sleeping more, the quality was poor. The students in the study reported concerns about academic performance and challenges of transitioning to an online learning format. Student were concerned about their grades. The findings of this study concluded that the COVID-19 pandemic negatively impacts students’ mental health in higher education.

Study Goals 1. To examine and compare PSQI questionnaire answers between two semesters of senior nursing students. 2. To examine and compare the demographics and grades of senior nursing students in Medical Surgical Nursing 2 and capstone courses between two semesters, one pre-pandemic and the other during the COVID-19 pandemic.

Method Design Approval for the voluntary, uncompensated study was obtained from the university’s institutional review board (IRB). The single site study was a private, nonsectarian, midsized, suburban university in the Northeastern United States. All data collection items were de-identified in their collection; thus, responses could not be linked to any participants. This prospective study took place over two semesters, one prior to the pandemic restrictions (fall 2019) and one during the pandemic restrictions (spring 2020). As this project was planned prior to the pandemic, the original plan was to collect data in a standardized format from nursing students taking part in their final course of their senior year; however, the data collection methods had to be altered between semesters. The data collected for this study included demographics and basic behavioral data pertaining to courses and eating and exercise habits among

others (see Table 1). The PSQI was also administered to collect sleep-related data (Buysse et al., 1988). The PSQI demonstrated evidence of the internal consistency reliability and construct validity in a number of research studies (Spira et al., 2012; Xiong et al., 2020). The pre-pandemic semester data were collected in person by a graduate assistant who was not associated with the class and who presented the study protocol to the students using a written script. Anonymized paper forms were collected by the graduate assistant and returned to the principal investigator in a sealed envelope. Per the statewide shutdown orders, during spring 2020, a recruitment email was sent to students by an administrator not associated with the class. The number of students participating pre-pandemic were (n = 71) and during pandemic (n = 59). Qualtrics data collection software was used for the pandemic semester and the data collected were completely anonymized. For consistency of analysis, data from the pre-pandemic semester were entered into Qualtrics by the graduate assistant allowing for the entire data set to be exported for analysis in R statistical software (R: A language and environment for statistical computing, 2020). Frequency distributions, bivariate analyses, and percentage comparisons were conducted using base R. To compile the PSQI scores according to the schema for accurate interpretation, an R package “PSQI.R” was downloaded and run (Yan & Zhou, 2020).

Results Demographic and Behavioral Data Participants each semester completed demographics including sex, age, race, working status, relationship status, living situation, and number of children (see Table 1). Additional questions included: Which semester are you in the nursing program? How many credits are you enrolled for this semester? Are you the caretaker for an aging or ill family member? Is there any life stressor outside of school which has impacted your performance this semester? Do you have any pre-sleep practices (e.g., sleep hygiene)? Is lack of sleep impacting your educational performance? How many hours are you spending on your clinical rotation? An assessment of diet, exercise, and prescription medication use showed an increase in frequent exercise from 29.58% (n = 21) prepandemic to 59.32%, (n = 35) during the pandemic. Eating three meals per day pre-pandemic was reported by 53.52% (n = 38) of respondents compared to 62.71% (n = 37) during the pandemic. Frequent consumption of sugary snacks prior to pandemic was reported as 39.44% (n = 28) and increased to 59.32% (n = 35) during the pandemic. Consumption of soda fell from 83.10% (n = 59) pre-pandemic to 71.19% (n = 42) during the pandemic. Similar decreases in regular coffee consumption were also observed from 73.24% (n = 52) pre-pandemic to 64.41% (n = 38) during the pandemic. Most medication use remained unchanged over time, including sleep medications (prescribed and non-prescribed) with 10.00% of respondents reporting their use. Similarly, anxiety medication (12.00%) and weight loss medications (1.00%) also remained stable across times. There was a change in “other prescribed medications” with 1.41% (n = 1) reporting pre-pandemic use compared to 13.79% (n = 8) during the pandemic. Pre-pandemic, 42.65% (n = 29) of students reported that sleep had a negative impact on school compared to 33.90% (n= 20) in the spring during the pandemic. Outside school stressors affecting life were

Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic

Table 1 Demographics

Fall 2019 students n = 71

Fall 19.00%

Spring 2020 students n = 59

Spring 20.00%

18–19

0.00%

20–25

73.24%

93.22%

26–30

15.49%

1.69%

31–35

5.63%

1.69%

> 35

5.63%

3.39%

Age N = 130

Gender N = 128

Fall 2019 students n = 70

Spring 2020 students n = 58

Men

14.29%

8.62%

Women

85.71%

87.93%

Other

3.45%

Race N = 129

Fall 2019 students n = 70

Spring 2020 students n = 59

Asian

8.57%

10.17%

Black

8.57%

10.17%

NH/PI

4.29%

1.69%

White

60.00%

57.63%

Multiracial

10.00%

16.95%

Other

8.57%

3.38%

Do you work? N = 125

Fall 2019 students n = 67

Spring 2020 students n = 58

Yes, full time

8.96%

0.00%

Yes, part time

68.66%

68.97%

22.39%

31.03%

Relationship status N = 127

Fall 2019 students n = 69

Spring 2020 students n = 58

Married

14.49%

12.07%

Single

75.36%

87.93%

Divorced

2.90%

0.00%

Partnered

7.25%

Living situation N = 128

Fall 2019 students n = 69

Spring 2020 students n = 59

On campus

2.9%

10.17%

Off campus

97.10%

89.83%

Children N = 127

Fall 2019 students n = 68

Spring 2020 students n = 59

Children 0

76.47%

76.27%

Children 1–5

23.53%

23.73%

Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic

During the pandemic, 33.90% of nursing students reported that lack of sleep negatively impacted their schoolwork, while 42.62% had previously reported lack of sleep as a factor negatively impact their schoolwork. The study by Lund et al. (2010) reported students demonstrated low sleep quality and perceived stress. Sleep quality increased in the spring 2020 semester in this study in contrast to the study by Wang et al. (2020), which reported negative outcomes on students sleep patterns during the pandemic. Additionally, the study by Wang et al. (2020) concluded that the COVID-19 pandemic negatively impacted sleep quality.

During the pandemic period spring 2020, students reported increased exercise, increased quality of sleep, eating three meals a day, and drinking less coffee and soda.

reported by 75% (n = 51) students pre-pandemic and increased to 91.53% (n = 54) during the pandemic. There was a similar increase in outside stressors impacting grades with 62.69% (n = 42) of students reporting outside stressors pre-pandemic compared to 81.36%, (n = 48) during the pandemic. According to the PSQI, 9.80% of students (n = 71) identified a sleep quality score indicating “good” pre-pandemic compared to 37.4% (n = 59) during the lockdown period.

Study Limitations There were several study limitations. The research was conducted in the Northeastern United States at only one private, nonsectarian, midsized, suburban university. The nursing students were all seniors in their final semester of a baccalaureate program and were not compared to any group(s) outside of their university. This was a descriptive quantitative comparative study lacking a control group. Conducting this study in another university setting or at a time other than during a pandemic may have revealed different results.

Discussion The authors believe the outcome of this study was influenced by the impact of the COVID-19 pandemic. Questions concerning sleep and its impact on nursing students during the pandemic were analyzed in this study. Subjects who reported consistent sleep schedules had higher GPAs in the study by Gaultney (2010). Our research data indicated the amount and quality of sleep improved during spring 2020, but GPAs were consistent between semesters. Outside stressors affecting grades were recorded as being higher in the spring of 2020, yet grades were not impacted pre- to post-pandemic. The study results revealed nursing students during the pandemic period made lifestyle changes to find balance and improve health. The students’ interpersonal environment changed during the lockdown period of the pandemic. In general, they did not attend school in person, worked less, lived in residential environments (home), and had more time for exercise and making healthier choices. Pender’s key concepts in the health promotion model (2010) include: person, environment, health, and that people seek to actively regulate their behavior and find a balance between stability and change. During the pandemic period spring 2020, students reported increased exercise, increased quality of sleep, eating three meals a day, and drinking less coffee and soda. Based on the propositions of Pender’s theory, students engaged in positive behaviors they personally valued, specifically health-promoting behaviors, demonstrating the capacity for reflective selfawareness regarding their individual health.

Conclusions As identified in Pender’s theory, an individual has the ability to regulate their own behavior. The impact of the COVID-19 pandemic in 2020 resulted in many students reporting an increase in sleep quality. This may be related to the shutdown of services, limited or non-existent socialization, the reduction in travel to classes, the reduction of clinical onsite courses, or to being sequestered. Additionally, the students worked fewer hours outside of classes during the pandemic than prior to the pandemic and had fewer activities available to them during the pandemic. There was also a decrease in medication, an increase in nutrition, and a decrease in the use of snack foods. Academic grades were not impacted from semester to semester. The importance of fostering a sense of communication, connection, support, and continuity of instruction among students during this time of remote learning, social distancing, and quarantine protocols was crucial. Students were supported with additional Zoom® internet contact with their faculty and advisors, as well as multiple administrative university-wide electronic alerts and contacts, which may have contributed to the results of the study.

Implications and Recommendations Nurse educators need to understand sleep disorders and the potential impact of sleep deprivation and pattern disruption on their students and their academic performance. This is especially important during times of additional stress, such as during a pandemic. Many variables have been identified that could place students at personal and academic risk, such as sleep patterns, rigor of academic requirements, COVID-19 protocols, and social isolation.

Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic

Promoting sleep interventions includes bedtime rituals; controlling room temperature; limiting artificial light, the use of computers, cell phones, and other technology at bedtime; controlling noise; and avoidance of stimulants such as caffeine, alcohol, tobacco, and exercise too close to one’s bedtime (American College Health Association, 2020). Nursing interventions include promoting sleep hygiene and educating students about sleep promotion and the limiting interruptions at bedtime. The implications for nursing education, science, and curriculum development related to the pandemic would also indicate issues such as

the impact of rigor and stress on the nursing student’s role. Future studies to expand the body of knowledge in this area should focus on long-term effects of sleep quality and pattern disturbance during unexpected times of stress and mandated change. A more complete study concerned with the effects of poor sleep and its impact on nursing students and the long-term effects should be addressed going forward. Additionally, a qualitative study or triangulated study in the future may contribute to the research evaluating the impact that pandemic fatigue has on sleep and sleep patterns and the academic performance of nursing students.

Journal of the New York State Nurses Association, Volume 48, Number 1

Impact of Sleep on Nursing Students in the Era of a Pandemic

n References American College Health Association. (2020). American College Health Association-National College Health Assessment III: Undergraduate Student Reference Group Executive Summary Fall 2019. Silver Spring, MD: American College Health Association. Billings, M. E., Hale, L., & Johnson, D. A. (2020). Physical and social environment relationship with sleep health and disorders. Chest, 157(5), 1304–1312. https://doi.org/10.1016/j.chest.2019.12.002 Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1988).The Pittsburg Sleep Quality Index, a new instrument for psychiatric practice and research. Psychiatric Research, 28, 193–213. https://doi.org/10.1016/0165-1781(89)90047-4 Detrich, S. K., Francis-Jimenex, C. M., Knibbs, M. D., Umali, I. L., & Trugilio-Londrigan, M. (2016). Effectiveness of sleep education programs to improve sleep hygiene and/or sleep quality in college students: A systematic review. JBI Database System Rev Implement Re, 14(9), 108–134. https://doi.org/10.11124/JBISRIR-2016-003088 Gaultney, J.F. (2010) The prevalence of sleep disorders in college students: Impact on academic performance. J Am Coll Health, 59(2), 91–7. https://doi.org/10.1080/07448481.2010.483708 Goel, N., Basner, M., Rao, H., & Dinges, D.F. (2013) Circadian rhythms, sleep deprivation, and human performance. Prog Mol Biol Transl Sci. 119, 155–190. https://doi.org/10.1016/B978-0-12-396971-2.00007-5 Henderson, V. (1966). The nature of nursing. In George, J. (Ed.). Nursing theories: The base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange. Jeong, J.Y., & Gu, M.O. (2018). Structural equation model for sleep quality of female shift work nurses. J Korean Acad Nurs, 48(5), 622–635. https://doi.org/10.4040/jkan.2018.48.5.622 Lund, H. G., Reider, B. D., Whiting, A. B., & Prichard, J. R. (2010). Sleep patterns and predictors of disturbed sleep in a large population of college students. Journal of Adolescent Health, 46, 124–13. Maslow, A. (1943). A theory of human motivation. Psychological Review, 50, 370–396. http://psychclassics.yorku.ca/Maslow/motivation.htm National Institute of Neurological Disorders and Stroke. (2020). Brain basics: Understanding sleep. https://www.ninds.nih.gov/Disorders/ Patient-Caregiver-Education/Understanding-Sleep Nightingale, N. (1992). Florence Nightingale’s notes on nursing. Scutari Press: The University of Michigan.

Pender, N. J., Murdaugh, C., & Parsons, M. A. (2010). Health promotion in nursing practice, 6th edition. Pearson/Prentice-Hall. Romero-Blanco, C., Rodríguez-Almagro, J., Onieva-Zafra, M. D., ParraFernández, M. L., del Carmen Praado-Laguna, M., & HernándezMartínez, A. (2020). Sleep pattern changes in nursing students during the COVID-19 lockdown. International Journal of Environ Res Public Health. 17(14). https://doi.org/10:3390/ijerph17145222 Rosso, A. C., Wilson, O. W., Papalia, Z., Duffey, M., & Bopp, M. (2019). Relationship between duration and quality of sleep on college student health behaviors and outcomes. Medicine & Science in Sports & Exercise, 51(Supplement), 526. https://doi.org/10.1249/01. mss.0000562081.10295 R: A language and environment for statistical computing. (2020). The R Foundation for Statistical Computing. https://www.R-project.org/ Spira, A. P., Beaudreau, S. A., Stone, K. L., Kezirian, E. J., Lui, L. Y., Redline, S., Ancoli-Isreael, S., Enrud, K., & Stewart, A. (2012). Reliability and validity of the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale in older men. J Gerontol A Biol Sci Med Sci, 67A(4), 433–439. https://doi.org/10.1093/gerona/glr172 Wang, X., Hegde, S., Son, C., Keller, B., Smith, A., & Sasangohar, F. (2020). Investigating mental health of U.S. college students during the COVID-19 pandemic: Cross sectional survey study. Journal of Medical Internet Research, 22(9), e22817. https://doi.org/10.2196/22817 Watson, N. F., Badr, M. S., Belenky, G., Bliwise, D. L., Buxton, O. M., Buysee, D., Dinges, D.F., Gangwisch, J., Grandner, M. A., Kushida, C., Malhotra, R.K., Martin, J. L., Patel, S. R.,Quan, S. F., & Tasali, E. (2015). Recommended amount of sleep for a healthy adult: A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep, 38 (6), 843–844. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4434546/ Xiong, P, Spira, A. P, & Hall, B. J. (2020). Psychometric and Structural Validity of the Pittsburgh Sleep Quality Index among Filipino domestic workers. Int J Environ Res Public Health, 17(14), 5219. https://doi. org/10.3390/ijerph17145219 Yan, W. & Zhou, W. (2020). PSQI: Scoring of the Pittsburgh Sleep Quality Index (PSQI). R Package Documentation. https://rdrr.io/github/ wzhou7/Fruved/man/PSQI.html

Journal of the New York State Nurses Association, Volume 48, Number 1

THE

JOURNAL of the New York State Nurses Association

Call for Papers

Call for Editorial Board Members

The Journal of the New York State Nurses Association is currently seeking papers.

Help Promote Nursing Research

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org.

The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board. Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review. Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org.

Journal of the New York State Nurses Association, Volume 48, Number 1

What’s New In The Healthcare Literature

n WHAT’S NEW

IN HEALTHCARE LITERATURE n Clinical Practice Guidelines on Pharmacologic Glycemic

Treatment in Type 2 Diabetes

n American Diabetes Association. (2020, September 30). https://reference. medscape.com/viewarticle/938182 The American Diabetes Association (ADA) published new guidelines on pharmacologic glycemic treatment for patients with type 2 diabetes mellitus. Some of the updated ADA Standards of Medical Care in Diabetes are as follows:  F or type 2 diabetes treatment, metformin is the preferred initial pharmacologic agent.  Early initial combination therapy for some patients may lengthen the time to treatment failure.  Early introduction of insulin may be utilized, given certain metabolic indicators.  P harmacologic agent choice should be patient-centered, with consideration to comorbidities, patient preferences, impact on weight, risk for hypoglycemia, cost, and other individual concerns.  For patients with type 2 diabetes who have heart failure, kidney disease or cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or glucagon-like peptide-1 receptor agonist (GLP-1 RA) is recommended.  When glucose needs to be lowered more than oral agents are able, for type 2 diabetes patients, the use of GLP-1 RAs is preferred to that of insulin, when possible.

of hyperglycemia are present, or when hemoglobin A1c (HbA1c) or blood glucose levels are very high (HbA1c >10% [86 mmol/mol], blood glucose ≥16.7 mmol/L [300 mg/dL]).  Guidance regarding the choice of pharmacologic agents should arise from a patient-centered approach. Cardiovascular comorbid conditions, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences are among the factors that should be taken into consideration.  A sodium-glucose cotransporter-2 (SGLT2) inhibitor or glucagonlike peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease (CVD) benefit is recommended for patients with type 2 diabetes who have established atherosclerotic CVD (ASCVD) or indicators of high risk or who are suffering from established kidney disease or heart failure.  When, in patients with type 2 diabetes, glucose needs to be lowered to a greater extent than can be accomplished with oral agents, the use, when possible, of GLP-1 RAs is preferred to that of insulin.  Reevaluate the patient’s medication regimen and medication-taking behavior at regular intervals (every 3 to 6 months), adjusting them as needed to incorporate specific factors that affect treatment choice.  An SGLT2 inhibitor is recommended in patients with heart failure of chronic kidney disease (CKD). A GLP-1 RA should be administered in those cases in which an SGLT2 inhibitor cannot be employed.

 It is preferred that metformin be employed as the initial pharmacologic agent for type 2 diabetes treatment.

 In deciding which medication to add to metformin, it must first be determined whether the patient has established ASCVD or a high ASCVD risk (patients aged ≥55 years with coronary, carotid, or lower-extremity artery stenosis >50% or left ventricular hypertrophy), heart failure, or established CKD. If one of these characteristics if present, it is recommended that an SGLT2 inhibitor or a GLP-1 RA with demonstrated CVD benefit be used.

 To lengthen the time to treatment failure, consideration in some patients can be given to early combination therapy at initiation of treatment.

 It is recommended that insulin therapy be administered to reduce glucotoxicity and lipotoxicity in patients with symptoms from advanced hyperglycemia.

In September 2020, the American Diabetes Association (ADA) published clinical practice guidelines on pharmacologic glycemic treatment in patients with type 2 diabetes mellitus, as an update to the ADA’s Standards of Medical Care in Diabetes.[1,2]

 Consideration should be given to the early introduction of insulin if evidence exists of ongoing catabolism (weight loss), if symptoms

Journal of the New York State Nurses Association, Volume 48, Number 1

What’s New In The Healthcare Literature

Smartphone App iCanQuit Effective as Smoking Cessation Aid n Medscape. (2020, September 23). https://www.medscape.com/ viewarticle/937779

guidelines. Adult cigarette smokers were randomly assigned to use one of the apps for the duration of a year.

Smartphone apps may be a free or low-cost smoking cessation treatment with broad reach. Like apps for anything else, some stand apart from the rest. A recent clinical trial compared an app based on acceptance and commitment therapy (ACT) with one based on U.S. clinical practice

The iCanQuit app was based on ACT while QuitGuide from the National Cancer Institute was based on clinical guidelines directed at the avoidance of smoking behaviors. The iCanQuit app was found to have a 50% increase in 12-month quit rates.

AHA Adds Recovery, Emotional Support to CPR Guidelines n Medscape. (2020, October 27). https://www.medscape.com/ viewarticle/939860 The American Heart Association (AHA) has updated its guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Advances in AHA practice guidelines have continued to improve in-hospital cardiac arrest outcomes. In 2015, the AHA, to keep pace with rapid advances in science, technology, and assistive products, shifted from releasing practice updates every five years to maintaining continuous online review. The first recent update addresses opioid overdose related mortality. It advises bystanders and trained rescuers to immediately activate emergency services and initiate CPR for individuals in known or suspected cardiac arrest. The second seeks to improve health disparities in CPR training which, in turn, improve the rates of bystander CPR and poorer outcomes among minority and populations of lower socioeconomic status. Targeted training approaches and use of mobile technology to alert trained bystanders who can respond to an emergency call may improve community outcomes.

of Pennsylvania, Philadelphia, and colleagues. In 2015, the committee shifted from 5-year updates to a continuous online review process, citing a need for more immediate implementation of practice-altering data, they wrote in Circulation. And new approaches do appear to save lives, at least in a hospital setting. Since 2004, in-hospital cardiac arrest outcomes have been improving, but similar gains have yet to be realized for out-of-hospital cardiac arrest. “Much of the variation in survival rates is thought to be due to the strength of the Chain of Survival, the [five] critical actions that must occur in rapid succession to maximize the chance of survival from cardiac arrest,” the committee wrote.

Update Adds Sixth Link to Chains of Survival: Recovery

“Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae The Chain of Survival has added a sixth link, recovery, drawing focus of cardiac arrest and optimize transitions of care to independent physical, on physical, social, and emotional recovery aspects following resuscitation. social, emotional, and role function,” the committee wrote. For clinicians, the use of epinephrine as soon as possible during CPR Merchant and colleagues identified three “critically important” and use of cuffed endotracheal tube, rapid response to clinical seizures and recommendations for both cardiac arrest survivors and caregivers non-convulsive status epilepticus are now recommended. For more, see the during the recovery process: structured psychological assessment; full article in Medscape. multimodal rehabilitation assessment and treatment; and comprehensive, Highlights of new updated guidelines for cardiopulmonary resuscitation multidisciplinary discharge planning. The recovery process is now part of all and emergency cardiovascular care from the American Heart Association four Chains of Survival, which are specific to in-hospital and out-of-hospital include management of opioid-related emergencies; discussion of health arrest for adults and children. disparities; and a new emphasis on physical, social, and emotional recovery after resuscitation. The AHA is also exploring digital territory to improve CPR outcomes. The guidelines encourage use of mobile phone technology to summon trained laypeople to individuals requiring CPR, and an adaptive learning suite will be available online for personalized CPR instruction, with lessons catered to individual needs and knowledge levels. These novel approaches reflect an ongoing effort by the AHA to ensure that the guidelines evolve rapidly with science and technology, reported Raina Merchant, MD, chair of the AHA Emergency Cardiovascular Care Committee and associate professor of emergency medicine at the University 66

New Advice on Opioid Overdoses and Bystander Training Among instances of out-of-hospital cardiac arrest, the committee noted that opioid overdoses are “sharply on the rise,” leading to new, scenario-specific recommendations. Among them, the committee encouraged lay rescuers and trained responders to activate emergency response systems immediately while awaiting improvements with naloxone and other interventions. They also suggested that, for individuals in known or suspected cardiac arrest, high-quality CPR, including compressions and ventilation, should be prioritized over naloxone administration.

Journal of the New York State Nurses Association, Volume 48, Number 1

What’s New In The Healthcare Literature

In a broader discussion, the committee identified disparities in CPR training, which could explain lower rates of bystander CPR and poorer outcomes among certain demographics, such as Black and Hispanic populations, as well as those with lower socioeconomic status. “Targeting training efforts should consider barriers such as language, financial considerations, and poor access to information,” the committee wrote. While low bystander CPR in these areas may be improved through mobile phone technology that alerts trained laypeople to individuals in need, the committee noted that this approach may be impacted by cultural and geographic factors. To date, use of mobile devices to improve bystander intervention rates has been demonstrated through “uniformly positive data,” but never in North America. According to the guidelines, bystander intervention rates may also be improved through video-based learning, which is as effective as in-person, instructor-led training. This led the AHA to create an online adaptive learning platform, which the organization describes as a “digital resuscitation portfolio” that connects programs and courses such as the Resuscitation Quality Improvement program and the HeartCode blended learning course. “It will cover all of the guideline changes,” said Monica Sales, communications manager at the AHA. “It’s really groundbreaking because it’s the first time that we’re able to kind of close that gap between new science and new products.” The online content also addresses CPR considerations for COVID-19, which were first addressed by interim CPR guidance published by the AHA in April. According to Alexis Topjian, MD, coauthor of the present guidelines and pediatric critical care medicine physician at Children’s Hospital of Philadelphia, CPR awareness is more important now than ever. “The major

message [of the guidelines] is that high-quality CPR saves lives,” she said. “So push hard, and push fast. You have the power in your hands to make a difference, more so than ever during this pandemic.” Concerning coronavirus precautions, Topjian noted that roughly 70% of out-of-hospital CPR events involve people who know each other, so most bystanders have already been exposed to the person in need, thereby reducing the concern of infection. When asked about performing CPR on strangers, Topjian remained encouraging, though she noted that decisionmaking may be informed by local coronavirus rates. “It’s always a personal choice,” she said.

More for Clinicians For clinicians, Topjian highlighted several recommendations, including use of epinephrine as soon as possible during CPR, preferential use of a cuffed endotracheal tube, continuous EEG monitoring during and after cardiac arrest, and rapid intervention for clinical seizures and of nonconvulsive status epilepticus. From a pediatric perspective, Topjian pointed out a change in breathing rate for infants and children who are receiving CPR or rescue breathing with a pulse, from 12–20 breaths/min to 20–30 breaths/min. While not a new recommendation, Topjian also pointed out the lifesaving benefit of early defibrillation among pediatric patients. The guidelines were funded by the AHA. The investigators disclosed additional relationships with BTG Pharmaceuticals, Zoll Foundation, the National Institutes of Health, and others.

Journal of the New York State Nurses Association, Volume 48, Number 1

What’s New In The Healthcare Literature

‘Landmark’ Study Pushed Detection of Covert Consciousness in TBI n Medscape. (2020, October 28). https://www.medscape.com/ viewarticle/939897 The science of recognizing and confirming signs of consciousness in traumatic brain injury (TBI) afflicted patients has made advances. Using a multimodal approach, early detection of covert consciousness, also called “cognitive motor dissociation” (CMD), predicts positive one-year and longterm outcomes. Unconscious acute TBI patients showed substantial EEG activity in response to complex stimuli including verbal commands for envisioning. Forty-four percent of patients with CMD, but only 14% of non-CMD patients demonstrated meaningful functional outcome, one year following injury, where they can take care of themselves for 8 hours per day. Implications for use are many. Families often make decisions to withdraw care from brain-injured patients based on the belief there is no chance for recovery. This would improve the accuracy of information used for rehabilitative and life-saving decision-making process. The European Academy of Neurology’s Panel on Coma, Disorders of Consciousness guideline recommends a comprehensive approach to the assessment and diagnosis of consciousness. This includes use of task-based fMRI, EEG and Glasgow Outcome Scale, behavioral and other exams to form accurate diagnoses of consciousness. Compelling advances in the ability to detect signs of consciousness in unconscious patients who have experienced TBI are leading to unprecedented changes in the field. There is now hope of improving outcomes and even sparing lives of patients who may otherwise have been mistakenly assessed as having no chance of recovery. “Importantly, it is the first compelling evidence that early detection of covert consciousness also predicts 1-year outcomes in the Glasgow

Outcome Scale Extended (GOSE), showing that covert consciousness in the ICU appears to be relevant for predicting long-term outcomes, “The researchers showed that 15% of unconscious patients with acute brain injury in the study exhibited significant brain activity on EEG in response to stimuli that included verbal commands such as envisioning that they are playing tennis. Although other studies have shown similar effects with task-based stimuli, the NEJM study further showed that a year later, the patients who had shown signs of covert consciousness, also called “cognitive motor dissociation” (CMD), were significantly more likely to have a good functional outcome, said the study’s senior author, Jan Claassen, MD, director of critical care neurology at Columbia University, in New York City, who also presented during the ANA session. “Importantly, a year later after injury, we found that 44% of patients with CMD and only 14% of non-CMD patients had a good functional outcome, defined as a GOSE score indicating a state where they can at least take care of themselves for 8 hours in a day,” he said. In the European Academy of Neurology (EAN) guideline, the academy’s Panel on Coma, Disorders of Consciousness, recommends that task-based fMRI, EEG, and other advanced assessments be performed as part of a composite assessment of consciousness and that a patient’s best performance or highest level of consciousness on any of those tests should be a reflection of their diagnosis, Edlow explained. “What this means is that our field is moving toward a multimodal assessment of consciousness in the ICU as well as beyond, in the subacute to chronic setting, whereby the behavioral exam, advanced DG, and advanced MRI methods all also contribute to the diagnosis of consciousness,” he said.

Journal of the New York State Nurses Association, Volume 48, Number 1

n CE Activity: A Time-Limited Look at Whether the New York State

Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting

Thank you for your participation in “A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

OBJECTIVES By completion of the article, the reader should be able to: 1. Compare the definitions of WPV. 2. Identify federal and state efforts addressing WPV. 3. Discuss the extent of WPV. 4. Analyze efficacy of laws, rules, and guidance in WPV mitigation.

INSTRUCTIONS In order to receive contact hours for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test and evaluation form, and earn 80% or better on the post-test. This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made out to NYSNA) or by credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form directions for more information. The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. NYSNA wishes to disclose that no commercial support was received for this educational activity. All planners and authors involved with the development of this independent study have declared that they have no vested interest. NYSNA program planners and authors declare that they have no conflict of interest in this program.

5. Identify ways to mitigate violence in the workplace. Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer. The 1.0 contact hour for this program will be offered until March 10, 2024. 1) The literature suggests that the use of unit-level violence data to facilitate action plans for unit-based violence prevention can effectively reduce the risk of violent events and injuries compared with plans that are not data driven. a. True b. False 2) Providing locator badges with panic buttons can expedite aid to victims. a. True b. False

INTRODUCTION Even though the actual number of workplace violence (WPV) incidents is substantially underreported by nurses, the U.S. Bureau of Labor Statistics (2018) reported that healthcare industry workers, more than all other industries, still experienced the highest rate of injuries caused by WPV. Violence toward healthcare workers may not always result in physical injury, but may cause psychological injury, influencing reduced work satisfaction, increased sleep disorders, burnout, depression, and post-traumatic stress disorder. Psychological injury is also correlated to subsequent negative impact on individual well-being and career, as well as quality of life and direct financial losses to employers. This article presents findings from a study that analyzes whether federal and state laws, regulations, and guidance significantly reduce the incidences of WPV against nurses in New York healthcare settings. It explores whether there are measures that can be taken by nurses’ unions and organizations to significantly reduce the incidences of WPV against nurses in healthcare settings. LEARNING OUTCOMES Participants will be able to recognize the extent of the WPV problem in health care and site two advocacy actions nurses can undertake to mitigate WPV in their workplaces.

3) Workplace violence may be physical, written, or verbal in nature. a. True b. False 4) Although the New York State Violence Against Nurses law made it a felony to assault an on-duty registered nurse (RN), it is unclear whether the law has effectively lowered rates of violence against nurses. a. True b. False 5) A pilot study by NYSNA members demonstrated that the number of actual assaults of RNs exceeds the numbers reported in OSHA logs in healthcare settings while verbal violence is neither reported or recorded, upholding findings in the literature. a. True b. False

Journal of the New York State Nurses Association, Volume 48, Number 1

6) Overcrowding and insufficient resources, such as qualified staff, may contribute to the escalation in WPV toward nurses. a. True b. False

9) There is an overall trend in workplace violence statistics toward an increase in the number of nonfatal occupational injuries and illnesses in general, but especially in the private healthcare industry. a. True b. False

7) According to NIOSH classification, one of the most common types of WPV in healthcare involves personal relationships (Type IV) as opposed to involvement with customers, clients, or patients (Type II).

10) The highest rates of nonfatal intentional injury to workers among all healthcare settings was in nursing and residential care facilities.

a. True

b. False

8) Calling for a 1-to-1 provider-to-patient ratio for violent patients and flagging potentially violent patients are ways nurses can proactively reduce WPV in their practice setting. a. True b. False

Journal of the New York State Nurses Association, Volume 48, Number 1

The Journal of the New York State Nurses Association, Vol. 48, No. 1

Answer Sheet A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting Note: The 1.0 contact hour for this program will be offered until March 10, 2024. Please print legibly and verify that all information is correct. First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY State? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE”). Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

CVV# Date:

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or email to: education@nysna.org or fax to: 212-785-0429 Journal of the New York State Nurses Association, Volume 48, Number 1

The Journal of the New York State Nurses Association, Vol. 48, No. 1

Learning Activity Evaluation

A Time-Limited Look at Whether the New York State Felony D Law or Workplace Violence Programs Mitigate Violence Against Nurses in the Healthcare Setting Please use the following scale to rate statements 1–7 below:

Poor

Fair

Good

Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity. 2. The content fulfills each of the CE Activity objectives. 3. The CE Activity subject matter is current and accurate. 4. The material presented is clear and understandable. 5. The teaching/learning method is effective. 6. The test is clear and the answers are appropriately covered in the CE Activity. 7. How would you rate this CE Activity overall? 8. Time to complete the entire CE Activity and the test?

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Journal of the New York State Nurses Association, Volume 48, Number 1

n CE Activity: Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic

Thank you for your participation in “Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic,” a new 1.0 contact hour continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer. The 1.0 contact hour for this program will be offered until March 10, 2024.

1) Some states limit patient access to medication-assisted treatment (MAT) by limiting NP prescription privileges for buprenorphine treatment. a. True b. False 2) Private insurers provide complete coverage for treatment, whereas public insurance is lacking. a. True b. False 3) CDC guidelines for dose limiting opioid treatment have no foreseeable adverse consequences. a. True b. False 4) Approximately half of all persons who are qualified for opioid use treatment actually gain access to such care.

INTRODUCTION

a. True

Opioid overdose-related death is a leading cause of death in the United States. Factors such as lack of effective alternative analgesic medication and overprescription of opioids have contributed substantially to substance use disorder (SUD) and overdose. With 2.1 million people suffering from SUD, drug overdose is a leading cause of injury-related death in America. The opioid crises affects every race, age, gender, and region of the country. Nurse practitioners are in the position to identify, educate, and aid persons about this issue. Federal law, state, and community efforts have sought to reduce SUD and the incidence of opioid-related death. However, several barriers are identified in this article that must be overcome in order to provide access to meaningful treatment and to prevent new addiction.

b. False 5) Approximately 80% of people who abuse opioids also consume excessive amounts of alcohol. a. True b. False 6) Patients who are of lower socioeconomic class and who are White tend to be at higher risk for opioid addiction. a. True b. False

LEARNING OUTCOME Participants should be able to identify two barriers nurse practitioners face in the treatment of persons with SUD.

7) The stigma of being someone who seeks treatment from opioid use disorder is, for people in some communities, a barrier to treatment.

OBJECTIVES

a. True

By completion of the article, the reader should be able to:

b. False

1. Identify the scope and significance of the opioid crises in the United States. 2. Identify opportunities in clinical practice to treat SUD. 3. Identify the research on barriers which nurse practitioners encounter in combating the opioid epidemic.

8) The MAT program consists entirely of pharmaceutical treatment for addiction. a. True b. False

Journal of the New York State Nurses Association, Volume 48, Number 1

9) Research indicates that literacy may be a factor in life expectancy for those suffering from SUD.

10) The requirement for prior authorization for MAT participation does not delay care or cost lives.

a. True

b. False

Journal of the New York State Nurses Association, Volume 48, Number 1

The Journal of the New York State Nurses Association, Vol. 48, No. 1

Answer Sheet Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic Note: The 1.0 contact hour for this program will be offered until March 10, 2024. Please print legibly and verify that all information is correct. First Name: MI: Last Name: Street Address: City: State: Zip Code: Daytime Phone Number (Include area code): Email: Profession: NYSNA Member # (if applicable):

Currently Licensed in NY State? Y / N (Circle one)

License #:

License State:

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD Check—payable to New York State Nurses Association (please include “Journal CE”). Credit Card:

Mastercard

Visa

Discover

American Express

Card Number: Name:

Expiration Date:

Signature:

CVV# Date:

Please print your answers in the spaces provided below. There is only one answer for each question.

1._________ 2._________ 3._________ 4._________ 5. _________

6._________ 7._________ 8._________ 9._________ 10._________

Journal of the New York State Nurses Association, Volume 48, Number 1

The Journal of the New York State Nurses Association, Vol. 48, No. 1

Learning Activity Evaluation

Barriers Impacting the Nurse Practitioner in Combating the Opioid Epidemic Please use the following scale to rate statements 1–7 below:

Poor

Fair

Good

Very Good Excellent

____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias?

Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Journal of the New York State Nurses Association, Volume 48, Number 1

131 West 33rd Street, 4th Fl., New York, NY 10001 1073

non-profit org. US postage paid century direct